Orthopedic Board Review MCQs: Hip, Shoulder & Spine

About This Board Review Set

This is Part 115 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 115

This module focuses heavily on: Hip, Shoulder, Spine.

Sample Questions from This Set

Sample Question 1: Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic...

Sample Question 2: A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh...

Sample Question 3: A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and...

Sample Question 4: A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mm P 3 P . What is the m...

Sample Question 5: An 18-year-old boxer sustained a blow to his right eye in a boxing match. Examination on the sideline reveals hyphema, reduced visual acuity and color vision, and a visual field cut. What is the next step in management? Review Topic...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Explanation

Most thoracic disk herniations occur in the lower (caudal) third of the thoracic spine. This predilection may be related to the unique anatomic and biomechanical environment of that region. The 11th and 12th ribs do not join the rib cage anteriorly and do not form a true articulation with the transverse processes posteriorly. Furthermore, flexion and torsional forces tend to concentrate between T10 and L1.

Question 2

A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh. Passive movement of the hip appears to elicit tenderness and very limited hip motion. A radiograph of the pelvis shows mild subluxation of the left hip. The next step in evaluation should consist of

Explanation

DISCUSSION: The diagnosis of bone and joint sepsis in a newborn is difficult because of the relative lack of obvious signs and symptoms. Fever is usually absent. A study of 34 newborns with osteomyelitis identified prematurity and delivery by cesarean section as predisposing factors. In that study, the most common clinical findings were pseudoparalysis, local swelling, and pain on passive movement. Because early diagnosis is so important, any infant who exhibits these findings should be suspected as having bone or joint sepsis. Once the area of involvement is identified, aspiration is mandatory. In newborns who have an infection about the hip, radiographs may reveal subluxation. In this patient, septic arthritis must be ruled out by aspiration of the hip. Developmental dysplasia of the hip is not painful and is not accompanied by localized swelling. If no purulent material is obtained at the time of hip aspiration, an arthrogram should be obtained to rule out epiphysiolysis of the proximal femur. Because the area of involvement has been identified by clinical examination, a gallium scan or MRI scan of the spine is not indicated.
REFERENCES: Knudsen CJ, Hoffman EB: Neonatal osteomyelitis. J Bone Joint Surg Br 1990;72:846-851.
Morrissy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 579-624.

Question 3

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Explanation

Patients older than age 40 years at the time of initial anterior dislocation have low rates of redislocation; however, 15% of these patients experience a rotator cuff tear. Moreover, there is a dramatic increase (up to 40%) in the incidence of rotator cuff tears in patients older than age 60 years. Axillary nerve injury may occur but is less common than rotator cuff tear.

Question 4

A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mm P 3 P . What is the most common organism in this scenario?

Explanation

DISCUSSION: The most common bacterial etiologic agent following varicella is group A beta-hemolytic streptococcus. The other organisms are much less common. Staphylococcus aureus is the most common bone infection organism. Staphylococcus epidermidis is increasingly a bone infection organism. Group B streptococcus occurs more commonly in newborns. Kingella kingae is a common joint pathogen but is not as common following varicella.
REFERENCES: Schreck P, Schreck P, Bradley J, et al: Musculoskeletal complications of varicella. J Bone Joint Surg Am 1996;78:1713-1719.
Mills WJ, Mosca VS, Nizet V: Orthopaedic manifestations of invasive group A streptococcal infections complicating primary varicella. J Pediatr Orthop 1996;16:522-528.

Question 5

An 18-year-old boxer sustained a blow to his right eye in a boxing match. Examination on the sideline reveals hyphema, reduced visual acuity and color vision, and a visual field cut. What is the next step in management? Review Topic

Explanation

With the examination demonstrating reduced visual acuity and visual field changes, emergent CT is needed to look for traumatic optic neuropathy from direct or indirect trauma. The most common mechanism is blunt facial trauma (78%), but penetrating trauma is also common (22%). The most common etiologies are sports and motor vehicle accidents. Fluorescein eye stain would only be useful for corneal abrasion or corneal foreign body. CT scans are often helpful for an orbital fracture, optic nerve sheath hemorrhage, optical canal fractures, skull fractures, foreign bodies, nonorbital facial fractures, or associated brain injuries. The presence of a fracture of the optic canal on a CT scan was a poor prognostic sign in a recent series by Goldenberg and associates. The treatment is controversial. Although treatment options include high-dose corticosteroids, retrobulbar steroid injection, optic canal decompression, and optic sheath fenestration, there is no consensus as to the optimum treatment. It has been reported that treatment does not alter the prognosis in children and adolescents. Only 29% to 44% of children and adolescent patients had significant improvement in visual acuity. Hyphema is a collection of free blood in the anterior chamber of the eye. It is the most common intraocular eye injury associated with sports as reported by Denyi and associates, and occurs in 24% of injured eye cases. At the time of injury, it occurs as a haze in the anterior chamber. An eye patch and ophthalmology evaluation in 2 days is inappropriate because timely evaluation in this scenario is important. High-dose steroids are often used for this injury but not before a full evaluation including a CT scan. Observation is not appropriate because the injury needs an urgent evaluation.

Question 6

Which examination finding points toward a brachial plexus injury rather than root avulsion?

Explanation

EXPLANATION:
A brachial plexus injury distal to the root level should leave the rhomboid muscle with intact function. Root avulsions of C5-6 will cause weakness of the rhomboids. The branching of the dorsal scapular nerve is proximal and often spared with upper brachial plexus injuries. Winging and biceps weakness may occur
with either injury, and an ipsilateral fracture does not differentiate an avulsion from a brachial plexus injury.

Question 7

Figure 92 is the radiograph of a 45-year-old man who was thrown from his horse and now reports groin pain. Which of the following is the most common long-term sequelae of this injury?

Explanation

The radiograph reveals an anterior posterior compression injury to the pelvic ring which is commonly seen after horseback riding injuries. In a large series of patients with this type of injury, 18 of 20 patients had sexual dysfunction after sustaining this injury. Posttraumatic osteoarthritis of the sacroiliac joints may occur, but is less common in this type of injury. Chronic low back pain, gait abnormalities, and quadriceps weakness are not typically seen with this type of injury.

Question 8

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient’s severe weakness and inability to elevate the arm.
REFERENCE: Gerber C, Myer DC, Schneeberger AG, et al: Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: An experimental study in sheep. J Bone Joint Surg Am 2004;86:1973-1982.

Question 9

Which of the following procedures is not part of the routine evaluation of a patient with suspected metastatic disease to bone?

Explanation

DISCUSSION: The work-up for a patient with an unknown primary lesion that is metastatic to bone includes a search for the primary tumor and other sites of metastasis. This involves conducting a thorough history and physical examination, appropriate laboratory studies, bone scan, chest radiograph, and CT of the chest, abdomen, and pelvis. In women, a mammogram may be indicated. CT of the brain is not necessary in the early stages of a metastatic work-up.
REFERENCES: Simon MA, Bartucci EJ: The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986;58:1088-1095.
Frassica FJ, Gitelis S, Sim FH: Metastic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 10

A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 3. What is the most likely diagnosis?

Explanation

DISCUSSION: Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization.
REFERENCES: Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
Lee JK, Yao L: Stress fractures: MR imaging. Radiology 1988;169:217-220.

Question 11

Figures below show the radiograph and the MRI scan obtained from a 37-year-old woman with a 2-month history of left hip pain. Which presurgical factor is most commonly associated with a poor outcome after a hip joint salvage procedure?

Explanation

DISCUSSION:
MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the
Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge
score cannot be determined presurgically.

Question 12

A 78-year-old woman undergoes her third lumbar decompression and fusion from L3 to L5 without complication. On the morning of postoperative day 3, examination reveals painless, flaccid weakness of both lower extremities. She also has an absent bulbocavernous reflex and a mild saddle paresthesia. MRI scans of the lumbar spine are shown in Figures 26a and 26b. What is the most appropriate management at this time?

Explanation

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 13

A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation?

Explanation

DISCUSSION: Severe lower extremity injury patients undergoing reconstruction have a higher rate of rehospitalization at 2 years. This question is based on data published by the LEAP study group, a multi-centered study of severe extremity injuries treated with either amputation or reconstruction.
Bosse et al found that at 2 years the SIP score and return to work were not statistically signficantly different between amputation and reconstruction groups. Reconstruction patients had a higher risk of rehospitalization. The psychosocial subscale of SIP did not improve with time. Risk factors for poorer SIP score were: rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation.
MacKenize et al evaluated factors influential in returning to work (RTW) after severe lower extremity injury. Characteristics that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW.

Question 14

A healthy, active 72-year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 1. A radiograph taken after the fall is shown in Figure 2. He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

Explanation

DISCUSSION:
This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

Question 15

In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic

Explanation

Femoroacetabular impingement is a mechanism for the development of early osteoarthritis for most nondysplastic hips. Early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients. There are two general types of femoroacetabular impingement. In cam impingement, the femoral deformity is usually a bump on the head-and-neck junction that impinges on the acetabular rim. The pincer type of impingement is caused by deformity on the acetabular side such as a deep socket or acetabular overcoverage due to retroversion. Both mechanisms create an obstacle for flexion and internal rotation.

Question 16

What factor is associated with a higher risk of dislocation after total hip arthroplasty?

Explanation

Dislocation after total hip arthroplasty is a multifactorial problem. Numerous risk factors may act independently or cumulatively to increase the risk of this complication. Previous hip surgery of any kind is associated with a twofold increased risk for dislocation. Other risk factors include female gender, impaired mental status, inflammatory arthritis, and older age. Numerous studies have shown a lower dislocation rate with a direct lateral approach, although surgical techniques such as capsular repair have significantly lowered the incidence of dislocation after using the posterior approach. Metal-on-metal bearings have been associated with other complications such as adverse tissue reactions but are often used with larger-diameter bearings, which pose a lower risk of dislocation.

Question 17

A 10-year-old girl has a right elbow deformity that is the result of trauma 5 years ago. She has no pain despite the arm deformity. The radiographs in Figures 42a and 42b show complete healing. This radiographic appearance demonstrates what complication?

Explanation

DISCUSSION: Cubitus varus is a common complication of displaced supracondylar humeral fractures that are treated with closed reduction and cast immobilization. Treatment with closed reduction and percutaneous pinning decreases the incidence of this complication. Cubitus varus also can occur in minimally displaced fractures when unrecognized collapse of the medial column of the distal humerus is not corrected with manipulation. This can be detected on physical examination of the carrying angle or on radiographs measuring Baumann’s angle, both in comparison to the opposite side. Cubitus varus may result in unacceptable cosmesis and may predispose the patient to fractures of the lateral condyle. The lateral radiograph demonstrates the crescent sign from overlap of the distal humerus with the olecranon seen in patients with cubitus varus. Patients with growth arrest to the medial trochlear physis would have atrophy of the trochlea on radiographs.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-45.
Papandrea R, Waters PM: Posttraumatic reconstruction of the elbow in the pediatric patient. Clin Orthop 2000;370:115-126.
Lins RE, Simovitch RW, Waters PM: Pediatric elbow trauma. Orthop Clin North Am 1999;30:119-132.

Question 18

Figure 68 is the radiograph of a 33-year-old runner who recently decided to begin running barefoot on trails. Since his transition to running without shoes 3 months ago, he has been having pain in the second metatarsophalangeal (MTP) joint. He feels like he is walking on a stone, notes edema in the ball of his foot, and has started to see a deviation of the second toe. What is the most likely etiology of these symptoms and findings?

Explanation

DISCUSSION
Lesser-toe plantar plate injuries are becoming increasingly recognized. Patients typically have an increase in pain, a positive Lachman test result upon examination, and deviation of the MTP joint. On radiograph, MTP subluxation can be appreciated. Nonsurgical treatment with a metatarsal pad may be attempted. Many patients who have surgery will have a partial or full tear of the plantar plate. The repair necessitates reinsertion of the plantar plate to the base of the proximal phalanx.
RECOMMENDED READINGS
Doty JF, Coughlin MJ, Weil L Jr, Nery C. Etiology and management of lesser toe metatarsophalangeal joint instability. Foot Ankle Clin. 2014 Sep;19(3):385-405. doi: 10.1016/j.fcl.2014.06.013. Epub 2014 Jul 10. PubMed PMID: 25129351. View Abstract at PubMed
Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014 Sep;35(9):876-85. doi: 10.1177/1071100714539659. Epub 2014 Jun 23. PubMed PMID:

Question 19

A 13-year-old girl with adolescent idiopathic scoliosis is otherwise healthy with a normal neurologic examination and she began her menstrual cycle 3 months ago. Standing radiographs show a high left thoracic curve from T1-T6 that measures 29 degrees, a right thoracic curve from T7-L1 that measures 65 degrees, and a left lumbar curve from L1-L5 that measures 31 degrees, correcting to 12, 37, and 10 degrees, respectively, on bending films. Her Risser sign is 1. What is the most appropriate management?

Explanation

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and
14 • American Academy of Orthopaedic Surgeons
posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.
REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

Question 20

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Explanation

DISCUSSION: By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.
Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.
Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is rarely indicated in the proximal and middle tibia.

Question 21

Figure 56 is the radiograph of an otherwise healthy 3-year-old boy who fell and sustained the isolated injury shown. What is the best treatment modality?

Explanation

DISCUSSION
At 3 years of age, children do well with nonsurgical treatment with early spica casting and early mobilization. There is no indication to perform surgical stabilization in such a closed isolated injury. The fracture is not shortened unacceptably according to clinical practice guidelines, and traction for this fracture is unnecessary. Traction also may be problematic for the family and healthcare system.
RESPONSES FOR QUESTIONS 57 THROUGH 62
Cortical thickening in the region of the lesion
Erosive metaphyseal lesion with loss of cortical integrity
Normal bony anatomy on radiographs
Diffuse articular erosion with loss of joint space
Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
Eccentric well-circumscribed metaphyseal lesion with a scalloped border
Match the orthopaedic condition described below with the expected radiographic finding listed above.

Question 22

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management?

Explanation

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 23

A patient undergoes a proximal tibial resection that is reconstructed with a fresh frozen osteoarticular allograft. Eleven months later, the graft is retrieved. Histologically, the articular cartilage and subchondral bone retrieved would be expected to show evidence of

Explanation

DISCUSSION: Osteoarticular allografts are devoid of host chondrocytes but do contain “mummified” cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact.
REFERENCES: Enneking WF, Campanacci DA: Retrieved human allografts:

A clinicopathological study. J Bone Joint Surg Am 2001;83:971-986.
Enneking WF, Mindell ER: Observations on massive retrieved human allografts.

J Bone Joint Surg Am 1991;73:1123-1142.

Question 24

Plate fixation of olecranon fractures is recommended over tension band wire fixation when

Explanation

Tension band wire fixation of olecranon fractures is recommended for fracture patterns that are proximal to the coronoid process and are relatively transverse to withstand compressive forces. When comminution is present, a neutralization technique such as plating is preferred over a compressive technique such as tension band wire fixation. Such neutralization plating, if performed correctly, does not have the risk of narrowing the sigmoid notch as tension band wire fixation would. Fractures of the tip of the olecranon, transverse fractures, fractures associated with osteoporosis, and displaced fractures are all relative indications for tension band wire fixation.

Question 25

A 29-year-old woman is seen in the emergency department with a 24-hour history of severe back and leg pain precipitated by weight-lifting. The patient reports bilateral leg pain and is unable to urinate. She has dense anesthesia in the perineal region on examination. A MRI scan is shown in Figure 38. The patient is taken to surgery urgently. What is her prognosis for recovery? Review Topic

Explanation

The patient with cauda equina syndrome should be taken to surgery urgently to provide the best chance of symptom resolution. However, many studies indicate that patients with cauda equina syndrome do not return to a completely normal status even following urgent surgery. Whereas pain is typically relieved after surgery, other deficits, especially bladder and sexual dysfunction, may persist. Particularly in light of the patient's severe saddle anesthesia, she may have a poor prognosis for recovery of normal bladder function.

Question 26

Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?

Explanation

DISCUSSION: The most common deleterious side effect of ketamine is increased salivation and tracheobronchial secretions. For this reason, an antisialagogue agent should be given. While lack of sufficient respiratory depression is one of the major advantages of using ketamine, apnea can occur if the drug is given too rapidly intravenously. Emergence phenomena is common in adults but relatively rare in children.
REFERENCES: Furman JR: Sedation and analgesia in the child with a fracture, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 62-63.
White PF, Way WL, Trevor AJ: Ketamine: Its pharmacology and therapeutic uses. Anesthesiology 1982;56:119-136.
McCarty EC, Mencio GA, Walker LA, Green NE: Ketamine sedation for the reduction of children’s fractures in the emergency department. J Bone Joint Surg Am 2000;82:912-918.

Question 27

A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include

Explanation

Scheuermann’s Disease classically presents with >45o thoracic kyphosis and anterior wedging (5o or more) at three sequential vertebrae. Disc narrowing, end-plate irregularities, scoliosis, spondylosis, and Schmorl’s nodes are also seen. It’s more common in adolescents and males. Normally, these patients are treated (1) in a brace if the curve is progressive and Risser 3 or less,
(2) with surgical fusion if >75o and Risser 3 or less, (3) with surgical fusion if >65o and Risser 4/5 if necessary or symptomatic. Posterior instrumentation, anterior release and interbody fusion is the treatment of choice for curves >75o, or those >55o on hyperextension. Other causes of kyphosis include trauma, infection, spondylitis, bone dysplasia, neoplasia, neurofibromatosis.

Question 28

A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis? Review Topic

Explanation

The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta. There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.

Question 29

A 45-year-old recreational tennis player underwent arthroscopic decompression and mini-open repair of a small supraspinatus tendon tear 3 weeks ago after nonsurgical management failed to provide relief. He now has pain, swelling about the wound, erythema, and purulent drainage. The patient is returned to the operating room for irrigation, debridement, and cultures. What is the most common organism causing this infection?

Explanation

DISCUSSION: In a large series of mini-open rotator cuff repairs, an infection rate of at least 2% was found, with the majority of the infections caused by Propionibacterium acnes. To prevent this complication, the shoulder should be re-prepped before the mini-open incision is made to prevent bacterial contamination from the arthroscopic procedure.
REFERENCES: Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.
Settecerri JJ, Pitner MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1999;8:1-5.

Question 30

A 47-year-old male with a history of a Putti-Platt procedure 20 years ago presents with right shoulder pain with decreased range-of-motion. Radiograph is shown in Figure A. What is the most accurate diagnosis? Review Topic

Explanation

With a history of a Putti-Platt procedure with the radiograph, the patient most likely has post-capsulorrhaphy arthropathy.
Post-stabilization procedure arthritis is thought to occur due to changes in contact loading in the shoulder joint due to fixing the joint in an incongruent posistion. It can be severe and debilitating, and lead to arthroplasty as a salvage procedure. The Putti-Platt procedure involves a division of the subscapularis tendon and anterior capsule, and realignment of the lateral tendon stump and capsule sewn into the anterior glenoid neck capsular insertion. The "pants-over-vest" style of repair is then finished by sewing the medial tendon stump into the tuberosity, so that external rotation is significantly limited by the soft tissue imbrication. There is no coracoid transfer for this stabilization procedure.
Bigliani et al. reported on a series of similar patients who developed arthritis following surgery for recurrent glenohumeral dislocation. Authors have theorized that instability repair may excessively tighten the joint in one direction and cause a fixed subluxation in the direction opposite from the side of repair, leading to severe degenerative arthritis due to inappropriate contact loading. 77% of patients following arthroplasty after post-capsulorrhaphy arthropathy had an excellent or satisfactory outcome, with improved pain and range of motion.
Figure A demonstrates severe osteoarthrosis of the affected shoulder, with significant joint space narrowing, periarticular osteophyte formation, and subchondral sclerosis.
Incorrect Answers:
performed for traumatic dislocation, but the best answer choice for this stem is Answer 2.

Question 31

Figure 1 depicts an intraoperative photograph obtained following proximal row carpectomy. The black dot denotes the capitate. The top of the figure is radial and the bottom of the figure is ulnar. Surgical disruption of the structure identified by the forceps would result in

Explanation

EXPLANATION:
The structure identified by the forceps is the radioscaphocapitate ligament. During a proximal row carpectomy, it is very important to identify and protect this ligament. Compromise of the ligament would result in ulnar translocation of the carpus and early failure of the proximal row carpectomy procedure. If the ligament is injured during surgery, immediate repair should be performed. Green and associates discuss the importance of the radioscaphocapitate ligament in stabilizing the carpus after this procedure is performed. Nakamura and associates compared 3-mm, 6-mm, and 10-mm radial styloidectomies, and only the 3-mm styloidectomy subsequently preserved carpal stability. Compromise of the radioscaphocapitate ligament occurred when larger portions of the radial styloid were excised. Distal radioulnar joint instability would result only from the disruption of the distal radioulnar joint stabilizers. Avascular necrosis would not occur, because the capitate receives its blood supply mainly from the palmar vessels. Finally, loss of active thumb IP flexion would not occur, because the flexor pollicis longus tendon would remain intact even if ligament compromise were to occur.

Question 32

A 52-year-old man who weighs 325 lb is wheelchair-bound from severe degenerative arthritis of the left hip. Twenty-four hours after cementless total hip arthroplasty, he develops shortness of breath and evaluation shows a saddle pulmonary embolus. The patient is started on enoxaparin sodium at 150 mg every 12 hours. Two days later, the patient’s hematocrit is 20% despite four units of transfused packed cells, and he now has developed a complete sciatic nerve palsy. What is the best course of action?

Explanation

DISCUSSION: The purpose of this question is to draw attention to the early risks of therapeutic anticoagulation that will be instituted by an intensivist or pulmonologist to treat a life-threatening pulmonary embolus. The temporary vena cava filter is a recent innovation but will effectively reduce the risk of further pulmonary emboli. This requires reversal of anticoagulation for safe insertion of the filter and creates a safe situation for additional surgical solutions. Sciatic nerve compromise was caused by the expanding hematoma in this patient, which could be mitigated by exploration both to assess the nerve and to remove a large hematoma that presents its own longterm risks.
REFERENCES: Della Valle CJ, Steiger DJ, Di Cesare PE: Thromboembolism after hip and knee arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:327-336.
Weil Y, Mattan Y, Goldman V, et al: Sciatic nerve palsy due to hematoma after thrombolysis therapy for acute pulmonary embolism after total hip arthroplasty. J Arthroplasty 2006;21:456-459.
American Academy of Orthopaedic Surgeons Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty, www.aaos.org/research/guidelines/ PEguide.asp

Question 33

A 45-year-old male presented to the trauma department 10 hours after sustaining a fracture-dislocation of his ankle. The patient underwent an attempted closed reduction of his ankle which can be seen in Figures A and B. The splint was removed, and the appearance of the leg is shown in Figure C. Regarding the best next step in management and the intended goals, which of the following is most accurate?

Explanation

The patient has hemorrhagic fracture blisters overlying the expected locations of incisions for definitive fixation of his ankle fracture, and therefore the next best step in treatment is external fixation. An external fixator will reduce the joint and provide relative stability during appropriate blister care until definitive open reduction internal fixation (ORIF).
Patients with high-energy periarticular fractures in the lower extremity are at risk for surgical wound complications due to compromised soft tissues. As in this case, joint dislocations can place harmful tension on the skin that leads to blistering and/or skin necrosis. An urgent reduction is indicated, and if it cannot be obtained with a closed manipulation alone, percutaneous or open treatment is indicated. Staged joint-spanning external fixation can both hold a reduction and allow access for skin or wound care prior to a definitive open reduction of an articular fracture. Fracture healing during external fixation occurs by enchondral ossification by way of the relative stability.
Strauss et al. developed a treatment protocol for the treatment of fracture blisters. They used silver sulfadine to minimize soft tissue complications by promoting re-epithelialization. After providone-iodine prep, each blister was unroofed by removing the overlying epithelium of the fracture. Once the blister was unroofed, silver sulfadiazine was applied and covered with dry gauze. They would then perform bid dressing changes. Extremities were deemed operable when skin wrinkles were visible on the overlying skin of the injured extremity.
Anglen et al. in a review of external fixation, report that fractures of the lower extremity are frequently associated with soft tissue trauma that precludes safe surgical treatment in the early period. They present a technique of temporary joint-spanning external fixation which allows stabilization of length and alignment while awaiting resolution of soft tissue swelling. They report no differences between patients who had a temporary external fixator and those who did not with respect to healing time, time to partial or full weight bearing, or clinical score.
Figures A and B demonstrate a pronation-external rotation type fracture with disruption of the syndesmosis. Figure C demonstrates fracture blisters.
Illustration A demonstrates an ankle-spanning external fixator. Illustration B demonstrates skin wrinkling to indicate that the skin is safe to incise.
Incorrect Answers:

OrthoCash 2020

Question 34

A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of

Explanation

DISCUSSION: Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
REFERENCES: Copeland CE, Bosse MJ, McCarthy ML et al: Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 1997;11:73-81.
Wright JL, Nathans AB, Rivara FP, et al: Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. J Urol 2006;176:1540-1545.

Question 35

A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match. Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise. Figures 6a and 6b show an AP radiograph and MRI scan. What is the most likely diagnosis?

Explanation

DISCUSSION: While difficult to appreciate on the AP radiograph of the shoulder, the increased physeal signal demonstrated on the axial MRI scan is consistent with a nondisplaced growth plate fracture. A comparison radiograph of the left shoulder also could be considered and the injured shoulder evaluated for physeal widening.
Proximal humeral fractures in children are somewhat unusual, representing less than 1% of all fractures seen in children and only 3% to 6% of all epiphyseal fractures. Physeal injuries are classified according to the Salter-Harris classification scheme. Salter-Harris type I fractures represent approximately 25% of physeal injuries to the proximal humerus in adolescents.
The proximal humeral physis is responsible for 80% of the longitudinal growth of the humerus; therefore, there is tremendous potential for remodeling of fractures in this region. Management for nondisplaced Salter-Harris type I fractures is limited to a short period of immobilization followed by a gradual return to activities as clinical symptoms resolve.
REFERENCES: Curtis RJ, Rockwood CA Jr: Fractures and dislocations of the shoulder in children, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 991-1007.
Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45:587-622.

Question 36

A 22-year-old man sustained a cervical fracture-dislocation of the C5-6 level in a motor vehicle accident along with an associated spinal cord injury. Six months after his injury, he has 4 out of 5 biceps on the left, with 5 out of 5 biceps on the right. Deltoid is graded at 5 out of 5 bilaterally. There is 0 strength in the triceps, wrist flexors, wrist extensors, and digital extensors. He has neurogenic bowel and bladder with absent perianal sensation and no voluntary motor in the lower extremities. The patient's neurologic deficit is best categorized as which of the following? Review Topic

Explanation

The patient has a complete spinal cord injury. The level of a spinal cord injury is determined by the most distal intact (5/5) function. The lowest motor intact level in this patient is C5 based on the described examination. Central spinal cord injury and Brown-STquard injuries are both incomplete patterns of spinal cord injury.

Question 37

A 57-year-old woman experiences pain 1 year after total knee arthroplasty (TKA). She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior-stabilized TKA without evidence of component loosening. What is the recommended treatment for this patient?

Explanation

DISCUSSION:
Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor
mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful total knee arthroplasty.

Question 38

Which of the following is considered a specific advantage of using COX-2 inhibitors over COX-1 inhibitors?

Explanation

DISCUSSION: Inflammation is mediated through two isoforms of cyclooxygenase that convert arachidonic acid to prostaglandins. Selectivity, but not specificity, is one of the unique characteristics of this process that has been able to provide more protection from the effects of gastric mucosal alterations using the COX-2 selective inhibitors. The use of COX-1 selective inhibitors is associated with side effects such as ulcerative conditions and platelet interference, both of which have been difficult to control in the past until the advent of the COX-2 inhibitors. PGE₂ inhibition by COX-1 in the intestinal track can then be bypassed, thereby reducing ulceration complications associated with use of nonsteroidal anti-inflammatory drugs.
REFERENCES: Lane JM: Anti-inflammatory medications: Selective COX-2 inhibitors. J Am Acad Orthop Surg 2002;10:75-78.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000.

Question 39

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows a displacement of C5 on C6 of approximately 25%. The CT scan shows a perched facet at C5-6. There is no evidence of a facet fracture. A bilateral facet dislocation would show a displacement of more than 50%.
REFERENCES: Rothman RH, Simeone FA (eds): The Spine, ed 4. Philadelphia PA, WB Saunders, 1999, pp 927-937.
Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. St Louis, MO, Mosby, 2003, pp 455-458.

Question 40

A 49-year-old woman noted pain in her right axilla 1 day after moving heavy furniture. Two weeks later, she now reports persistent numbness and paresthesias along the inner aspect of her upper arm radiating into the ulnar digits. Examination reveals full shoulder motion, tenderness over the first rib, and a decreased radial pulse with the shoulder placed overhead. What is the most likely diagnosis?

Explanation

DISCUSSION: Thoracic outlet syndrome is thought to be caused by compression of the neurovascular supply to the upper limb in the supraclavicular and axillary regions of the shoulder. While typically progressive in onset, thoracic outlet syndrome may develop after acute injury. Injury or weakness of the scapular muscles, especially the trapezius, may result in descent of the scapula and cause compression of the thoracic outlet. In general, most symptoms are the result of neural compression. Typical symptoms include pain in the neck or shoulder and numbness or tingling that predominantly involves the ulnar side of the arm and hand. Exacerbation of these symptoms is typical when the arm is abducted. Initial management should consist of postural exercises aimed at restoring proper scapular stability. Severe recalcitrant symptoms may warrant surgical decompression.
REFERENCES: Leffert RD: Thoracic outlet syndrome. J Am Acad Orthop Surg 1994;2:317-325.
Todd TW: The descent of the shoulder after birth: Its significance in the production of pressure-symptoms on the lowest brachial trunk. Anat Anz 1912;41:385-397.

Question 41

A 62-year-old man with a long history of ankylosing spondylitis has neck pain after lightly bumping his head on the wall. Examination reveals neck pain with any attempted motion; the neurologic examination is normal. Plain radiographs show extensive ankylosis of the cervical spine and kyphosis but no fracture. What is the next most appropriate step in management?

Explanation

DISCUSSION: A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine.
REFERENCES: Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998,

pp 724-727.
McDowell GS, Cammisa FP, Eismont FJ: Hyperextension injuries of the cervical spine, in Levine AM, Eismont FJ, Garfin SR, Zigler JE (eds): Spine Trauma. Philadelphia, PA,

WB Saunders, 1998, pp 372-374.

Question 42

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

Explanation

The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression.

Question 43

A 24-year-old man who was involved in a high speed motor vehicle accident is transferred for definitive care after having been diagnosed with an acute spinal cord injury from a fracture-dislocation at C6-7. He has a complete C6 neurologic level and it is now approximately 10 hours from his injury. What is the most appropriate pharmacologic treatment at this time?

Explanation

DISCUSSION: The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for

48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.
REFERENCES: Braken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
Kwon BK, Tetzlaff W, Grauer JN, et al: Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451-464.

Question 44

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Explanation

The reverse total shoulder arthroplasty depends on a functional deltoid muscle which is innervated by the axillary nerve to restore elevation for the patient. Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty has not been correlated with poor results with a reverse shoulder arthroplasty. As long as the patient does not have an active infection, prior infections are not a contraindication. Patients can still have pain and pseudoparalysis from a chronic rotator cuff tear, despite having normal cartilage, and they will still benefit from a reverse total shoulder arthroplasty if other treatments have failed.

Question 45

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 21. What is the most likely diagnosis?

Explanation

DISCUSSION: The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.
REFERENCES: Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome.

J Hand Surg Br 1992;17:510-512.
Seror P: Anterior interosseous nerve lesions: Clinical and electrophysiological features. J Bone Joint Surg Br 1996;78:238-241.

Question 46

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Explanation

DISCUSSION: Talar compression syndrome is also known as os trigonum syndrome or posterior ankle impingement syndrome and occurs in activities involving extreme ankle plantar flexion. It involves pinching of the posterior talus (os trigonum or posterior process of the talus) between the calcaneus and tibia. The flexor hallucis longus also may be impinged. The other structures are not commonly injured in this syndrome.
REFERENCES: Brodsky AE, Khalil MA: Talar compression syndrome. Am J Sports Med 1986;14:472-476.
Wredmark T, Carlstedt CA, Bauer H, Saartok T: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.
Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.

Question 47

A 58-year-old man reports a 2-month onset of groin pain with no history of trauma. Examination reveals that range of motion of the hip is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 20. Treatment should consist of

Explanation

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 48

Emergent management of acute tooth displacement (luxation) includes

Explanation

DISCUSSION: Avulsed teeth must be replanted immediately to enhance viability of the periodontal ligament cells on the root. With the tooth in place, the athlete should bite down on a towel to maintain stability. The athlete should be taken emergently to a dentist’s office or emergency room. The avulsed tooth should not be handled by the root or scrubbed to remove debris. If immediate replantation is not possible, the tooth should be transported in saline solution, milk, or saliva on gauze.
REFERENCES: Flores MT, Andreasen JO, Bakland LK, et al: Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001; 17:97-102.
Ranalli DN, Demas PN: Orofacial injuries from sport preventive measures for sports medicine. Sports Med
2002;2:409-418.

Question 49

A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?

Explanation

DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.

Question 50

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

Explanation

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.
REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy. Tech Hand Up Extrem Surg 1999;3:32-36.

Question 51

Autosomal dominant

Explanation

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following tumor suppressor genes is most likely involved:

Question 52

A 3-year-old boy sustains a complete paralysis following a high thoracic spinal cord injury consistent with a SCIWORA-type injury (spinal cord injury without radiographic abnormality). Subsequent progressive spinal deformity will develop in what percent of patients with this injury?

Explanation

DISCUSSION: Spinal cord injury in skeletally immature patients almost always leads to the development of paralytic spinal deformity. The age at injury is the most important factor affecting the development of scoliosis. Spinal cord injury that occurs more than 1 year prior to skeletal maturity is almost always followed by the development of scoliosis. In one study, scoliosis developed in 100% of children who were younger than age 10 years at the time of spinal cord injury. Scoliosis can occur after injury at any level. Spasticity is often a contributing factor. Up to two thirds of patients who have paralytic scoliosis prior to skeletal maturity will eventually require surgery for curve control.
REFERENCES: Mayfield JK, Erkkila JC, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg Am 1981;63:1401-1411.
Lancourt JE, Dickson JH, Carter RE: Paralytic spinal deformity following traumatic spinal cord injury in children and adolescents. J Bone Joint Surg Am 1981;63:47-53.
Dearolf WW III, Betz RR, Vogel LC, Levin J, Clancy M, Steel HH: Scoliosis in pediatric spinal cord injured patients. J Pediatr Orthop 1990;10:214-218.

Question 53

A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of

Explanation

DISCUSSION: Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043.
Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 54

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include

Explanation

DISCUSSION: The radiographs do not show significant arthrosis of the hallux metatarsophalangeal joint; therefore, arthrodesis is unnecessary. Orthotics will not correct the deformity. A distally based osteotomy will not achieve sufficient correction of the incongruity of deformity, and a Keller resection is not indicated in the younger population. The treatment of choice is a proximal metatarsal osteotomy with second toe correction.
REFERENCE: Mann RA, Rudicel S, Graves SC: Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy: A long-term follow-up. J Bone Joint Surg Am 1992;74:124-129.

Question 55

03 5.

Explanation

In long bones, radiographs initially show a radiolucency in the metaphysis that progresses into the diaphysis. The entire progression of the disease takes years.
The radiograph here shows the typical Paget’s lesion in the right iliac wing with mixed lytic and sclerotic areas.

Question 56

A patient who had previously undergone a salvage pelvic (Chiari) osteotomy now requires a total hip arthroplasty. The most frequent complication of this procedure is

Explanation

The Chiari osteotomy is recommended for patients with inadequate femoral head coverage and an incongruous joint. The osteotomy shortens the affected leg. It also medializes the hip's center of rotation. The osteotomy involves cutting the ileum at a spot above the acetabulum, which in effect abducts the acetabulum into a more vertical and medial position. The iliac wing then serves as a superior buttress. Answer #1 makes no sense. Answer #2 is wrong because the articular portion of the acetabulum remains unchanged. Answer #3 is incorrect because inferior coverage remains unchanged. Answer #4 is completely incorrect because superior coverage INCREASES with a Chiari osteotomy.

Question 57

Which of the following best describes heat stroke?

Explanation

DISCUSSION: Heat stroke consists of hyperthermia (greater than 105.8 degrees F
[41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than

Question 58

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Explanation

DISCUSSION: The T2-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on Trweighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 59

A 58-year-old male presents after a motor vehicle accident with severe pain and point tenderness over his lumbar spine. He is hemodynamically stable and full neurologic examination reveals no deficits. Radiographs showed no evidence of fracture. A CT was performed and is shown in Figure A. What is the most appropriate treatment of his injury. Review Topic

Explanation

The clinical presentation is consistent with a minimally displaced fracture that extends through all three columns on the spine in a patient with ankylosing spondylitis. The most appropriate treatment is posterior spinal instrumentation and fusion.
In patients with ankylosing spondylitis (AS), the rigid spine creates a long lever arm that makes even minimally displaced fractures potentially unstable. Thus, despite being minimally displaced in a neurologically intact patient, most fractures in AS warrant a posterior instrumentation and fusion, typically of three levels above and three levels below the fracture.
Caron et al. present a retrospective review of patients with ankylosed spines (due to AS or DISH) and characterize their fractures and outcomes of treatment. Cervical fractures were most common (55%) and rates of occurrence decreased as they progressed down the spine, with lumbar fractures seen only 8% of the time. They found the most common successful surgical intervention was multilevel posterior instrumentation and fusion (with decompression when necessary for neurologic compromise).
Wang et al. reviewed 12 cases of patients with AS who presented with traumatic spinal injuries. They reviewed clinical histories and available imaging. They found that MRI was the most sensitive test for identifying occult fractures of the spine, and recommend using MRI to rule out occult fractures as well as better characterize fractures seen on radiographs or CT imaging for patients with AS.
Werner et al. present a review of spinal fractures in patients with AS. They note that non-operative treatment of these fractures is reserved only for patients who have an unacceptably high risk of undergoing surgery. For three column thoracolumbar fractures they recommend surgical stabilization with a long posterior construct.
Figure A is a sagittal CT image of the lumbar spine with marginal syndesmophytes consistent with AS. The white arrow highlights a minimally displaced fracture that extends through all three columns on the spine. Illustration A are radiographs comparing DISH (on the left) with non-marginal syndesmophytes, and AS (on the right) with marginal syndesmophytes.
Incorrect Answers:

Question 60

A 10-year-old boy tripped as he was running down a hill, felt a painful pop in his right knee, and was unable to bear weight on the involved lower extremity. Examination reveals a tense effusion and an extensor lag of the right knee. Figures 36a and 36b show AP and lateral radiographs. Management should consist of

Explanation

DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism.
The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.
REFERENCES: Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990; 10:721 - 730. Question 37
When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?
Lateral femoral circumflex
Medial femoral circumflex
Superior gluteal
Inferior gluteal
Obturator
DISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.
REFERENCES: Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295- 1301.
Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 419-424.

Question 61

A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?

Explanation

DISCUSSION: Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed.
REFERENCES: Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.

Question 62

A well-healed bulk proximal tibia osteoarticular allograft is removed 10 years after implantation due to arthropathy. Histologic examination of the host allograft junction site will most likely reveal

Explanation

Retrieval studies of well-fixed bulk allografts reveal that the junction site heals with bridging external callus and there is persistence of callus perpendicular to the junction site. External callus is annealed to the surface of the allograft. There is very little penetration of the allograft and the bone graft is not remodeled. Direct osteonal penetration of the allograft with haversian remodeling defines primary bone healing seen in fractures, which does not occur with allografts. Fibrovascular tissue is seen early in the healing phase of the cancellous portion of the allografts.

Question 63

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Explanation

DISCUSSION: In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally.
REFERENCES: Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685.
Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996.

Question 64

Which of the following actions best enhances performance when an athlete is participating in a 10K race?

Explanation

DISCUSSION: Proper hydration prior to an athletic event is the most important determinant of performance. It is virtually impossible to keep pace with fluid loss during an athletic competition. When a net loss of fluid occurs and the athlete is properly prehydrated, this fluid loss will not adversely affect performance. It is not necessary to load up on carbohydrates prior to a 10K race, or to replace calories burned during the race. Hyponatremia can develop in ultra-endurance athletes, especially marathoners, if they hydrate without replacing electrolytes lost through sweating; however, this is highly unlikely for a 10K race.
REFERENCES: Newmark SR, Toppo FR, Adams G: Fluid and electrolyte replacement in the ultramarathon runner. Am J Sports Med 1991;19:389-391.
Noakes T: Fluid replacement during marathon running. Clin J Sports Med 2003;13:309-318.

Question 65

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Explanation

DISCUSSION: The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.
REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.

Question 66

A 30-year-old man who underwent an anterior lumbar diskectomy and fusion at L4-5 and L5-S1 through an anterior retroperitoneal approach 1 month ago now reports he is unable to obtain and maintain an erection. The most likely cause of this condition is

Explanation

DISCUSSION: Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction usually is nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-3 and S3-4 and usually are not involved in the surgical field for anterior L4-5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Johnson RM, McGuire EJ: Urogenital complications of anterior approaches to the lumbar spine. Clin Orthop 1981;154:114-118.

Question 67

A 25 year-old-male sustains a closed injury shown in Figure A. If a tibial intramedullary nail is placed with the starting points shown (arrows), what subsequent alignment will occur?

Explanation

In proximal third tibial shaft fractures, due to the deforming forces of the pes anserine and the extensor mechanism, utilizing standard starting points during intramedullary nailing (IMN) will result in a valgus and apex anterior deformity.
There are several tips and tricks to avoid subsequent deformity following tibial IMN of a proximal third fracture. One way to avoid deformity is to use a more lateral starting point than normal to ensure nail placement in the true center of the canal, which is more lateral when compared to the tibial plateau.
Walker et al. studied 12 cadaveric tibias and inserted a Kirschner wire depending on rotated views of the knee. In order obtain a perfect starting point, a perfect anteroposterior as well as lateral of the knee must be obtained; otherwise, the authors noted that malrotation is bound to occur. With a perfect view, a more lateral starting point correlated with the center of the tibial canal.
McConnell et al. studied cadaveric and subsequent radiographic correlation on a lateral knee x-ray to determine the ideal 'safe zone' for the starting point of a tibial nail. This safe zone is more lateral and posterior, when looking at the axial cut of the plateau.
Figure A exhibits a proximal third tibia fracture with starting points that are not lateral enough, and too distal (on the lateral view), which will result in apex anterior and valgus deformity.
Incorrect answers:

Question 68

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Explanation

DISCUSSION: Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.
Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.

Question 69

Figures A-C are images of a 37-year-old man who presents with isolated muscle atrophy due to a compressed nerve. Which of the following sequences correctly describes the pathway of this nerve through the brachial plexus, before it innervates the affected muscles?

Explanation

Figures A-C shows atrophy of teres minor and deltoid due to compression of the axillary nerve. The correct pathway of the axillary nerve within the brachial plexus is, C5-C6 nerve roots; upper trunk, posterior division, posterior cord.
Quadrilateral space syndrome is a condition defined by axillary nerve, +/- posterior humeral circumflex artery compression in the quadrilateral space. It most commonly affects the dominant shoulder in overhead movement athletes (e.g. basketball players) or other throwing athletes. Physical examination may reveal weakness with the arm positioned in abduction and external rotation. In situations of long-standing compression, there may also be atrophy of the teres minor and deltoid muscle.
Chafik et al. dissected thirty-one cadaveric human shoulders to describe the neuromuscular anatomy of teres minor. They showed that the primary nerve branch to teres minor travelled in a fascial sling 44 mm medial to the muscular insertion. This
area may be the potential site of greatest compression and tethering of this nerve in patients with isolated teres minor atrophy.
Friend et al. performed a cadaveric dissection of nine shoulder specimens to look at the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. These were compared to a case-based study of these two male patients with isolated atrophy of teres minor. They concluded that there is no good anatomical predictor of nerve compression outside the quadrilateral space as there is considerable anatomical variation in its origin and course, as well as potential site of compression.
Figure A-C are MRI images that show atrophy of the teres minor muscle and possibly deltoid muscle. The rotator cuff muscles are labeled in Illustration A. The teres minor muscle is labeled in Illustration B. Illustration C shows a diagram of the brachial plexus.
Incorrect
1:
This
describes
the
musculocutaneous
nerve.
3:
This
describes
the
suprascapular
nerve.
4:
This
describes
the
long thoracic
nerve.

Question 70

The dominant arterial blood supply to the patella enters at which anatomical location?

Explanation

The largest arterial contribution to the patella will enter at the distal (inferior) pole of the patella, with the dominant artery entering inferomedially.
The arterial blood supply to the patella is made up of branches of six main arteries: the descending genicular, the superior medial and lateral genicular, the inferior medial and lateral genicular, and the anterior genicular. Several of these branches contribute to the anastomotic network that surround the patella. From the ring, there are two main interosseous blood supply systems to enter the patella, known as the midpatellar and polar vessel systems. The distal pole of the patella is considered to be the largest arterial contribution to the peripatellar ring and the polar vessel system.
Lazaro et al. used twenty matched pairs of fresh-frozen cadaveric knees to isolate the dominant blood supply to the patella. After cannulating the superficial femoral artery, anterior tibialis artery, and posterior tibialis artery and performing magnetic resonance imaging, they found that the largest arterial contribution to the patella entered at the inferior pole in 100% of the specimens. In sixteen specimens (80%), the dominant artery entered the medial aspect of the distal pole. In three specimens (15%), it entered the lateral aspect of the distal pole.
Illustation A shows the arterial supply system to the patella. The dominant arterial supply enters at the distal (inferior) pole of the patella, with the dominant geniculate arteries entering inferomedially (labelled with a green star). Illustration B shows an anatomical illustration of the patellar blood supply. Note the dominant distal pole blood supply (arrow).
Incorrect Answers:

Question 71

A year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the
aspiration and proceed to a revision TKA with possible augments on standby.

Question 72

Which factor increases the success rate associated with all-inside lateral meniscal repair?

Explanation

DISCUSSION
Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular cartilage defects are not associated with improved healing rates.
RESPONSES FOR QUESTIONS 5 THROUGH 6
Physical therapy and a home exercise program
Corticosteroid injection
Arthroscopic debridement
Microfracture
Osteochondral autograft transplantation (OAT)
Match the treatment above with the clinical scenario below

Question 73

Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?

Explanation

DISCUSSION: The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a “bamboo spine” in the lumbar region. HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population. The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration.
REFERENCES: Calin A: Ankylosing spondylitis. Clin Rheum Dis 1985;11:41-60.
Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 431.
van der Linden S, Valkenburg H, Cats A: The risk of developing ankylosing spondylitis in HLA-B27 positive individuals: A family and population study. Br J Rheumatol 1983;22:18-19.

Question 74

A 32-year-old man underwent a total medial meniscectomy 2 years ago. He now reports pain and recurrent swelling for the past 3 months. Work-up includes full standing hip-knee-ankle radiographs, standing AP radiographs of both knees in full extension, an axial view of the patellofemoral joint, and a 45-degree flexion AP radiograph. Contraindication to meniscus allograft transplantation includes which of the following? Review Topic

Explanation

Flattening of the femoral condyles indicates the onset of significant arthritis of the joint and is a contraindication to meniscus allograft transplantation. Criteria to proceed with allograft transplantation includes prior total meniscectomy, age of 50 years or younger, BMI of less than 30, clinical symptoms of pain in the involved tibiofemoral compartment, 2 mm or more of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph, ligamentous stability, normal alignment, and no radiographic evidence of advanced arthrosis. Recurrent effusions are associated with chronic meniscus deficiency, and is one criteria for meniscal transplantation. High tibial osteotomy is often considered in conjunction with meniscal transplantation to correct tibiofemoral malalignment.

Question 75

A 17-year-old high school long distance runner is seeking advice before running a marathon for the first time. What advice should be given regarding his fluid, carbohydrate, and electrolyte intake around the time of the race?

Explanation

DISCUSSION: The goal of fluid replenishment should be to replace the sweat that has been lost. Sweat is mostly water, with a small concentration of salts and other electrolytes. Absorption is enhanced by solutions of low osmolality. Scientific research has also shown that adding carbohydrates to the drink improves athletic performance. Carbohydrates such as glucose and maltodextrins (glucose polymers) stimulate fluid absorption by the intestines. Fructose slows intestinal absorption of fluids. Drinks that are high in fructose, such as orange juice, can lead to gastrointestinal distress and osmotic diarrhea.
REFERENCES: Kirkendall D: Fluids and electrolytes, in The U.S. Soccer Sports Medicine Book. Baltimore, MD, Williams and Wilkins, 1996.
Gisolfi CV, Duchman SM: Guidelines for optimal replacement beverages for different athletic events. Med Sci Sports Exerc 1992;24:679-687.

Question 76

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Explanation

DISCUSSION: Of the incomplete spinal cord injuries, Brown-Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of the injury.
REFERENCES: Apple DF: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, pp 1130-1131.
Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 544-545.

Question 77

A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time?

Explanation

DISCUSSION: Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
REFERENCES: Findlay JM: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;39:210.
Dickman CA, Mamourian A, Sonntag VK, et al: Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. J Neurosurgery 1991;75:221-227.

Question 78

An 18-year-old man recently underwent an uncomplicated arthroscopic partial medial meniscectomy that was complicated by reflex sympathetic dystrophy (RSD), also termed “sympathetically maintained pain” (SMP). What is the most common finding of this condition?

Explanation

DISCUSSION: The hallmark for RSD or SMP is the presence of pain that is out of proportion to that expected for the degree of the injury. SMP often extends well beyond the involved area and is present in a nonanatomic distribution. The pain is frequently described as a burning sensation, with extreme sensitivity to light touch. Joint stiffness can be present but is a nonspecific finding. There may be cold intolerance, but this is not a cardinal symptom. Sweating actually may be increased. Osteopenia, if present, is a late finding.
REFERENCES: Lindenfeld TN, Bach BR Jr, Wojtys EM: Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Instr Course Lect 1997;46:261-268.
O’Brien SJ, Ngeow J, Gibney MA, Warren RF, Fealy S: Reflex sympathetic dystrophy of the knee: Causes, diagnosis, and treatment. Am J Sports Med 1995;23:655-659.

Question 79

In the preoperative planning of revision acetabular reconstruction, the surgeon should identify significant posterior column deficiency by noting which of the following radiographic features?

Explanation

DISCUSSION: Proximal and medial migration of the femoral head usually indicates deficiencies of the dome or anterior column. Wear of the polyethylene may result in osteolysis and impingement, which are not indicative of any major bone deficiency. A significant osteolytic lesion in the ischium may represent a major posterior column deficiency that can create a technical challenge during the reconstruction.
REFERENCES: Paprosky WG, Magnus RE: Principles of bone grafting in revision total hip arthroplasty: Acetabular technique. Clin Orthop 1994;298:147-155.
Campbell DG, Masri BA, Garbuz DS, Duncan CP: Acetabular bone loss during revision total hip replacement: Preoperative investigation and planning, in Zuckerman J (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 43-56.

Question 80

Based on the diagram shown in Figure 16, what muscle derives its innervation from the nerve identified by the letter “A”?

Explanation

DISCUSSION: The nerve labeled A is the axillary nerve, a branch from the posterior cord. The posterior cord innervates the subscapularis, latissimus dorsi, teres major and minor, deltoid, triceps, anconeus, brachioradialis, and extensors of the forearm. The axillary nerve innervates the teres minor and deltoid. The pectoralis minor is innervated by the medial cord. The supraspinatus and the subclavius are innervated by the superior trunk. The brachialis is innervated by the lateral cord.
REFERENCES: Moore K: Anatomy, ed 3. Philadelphia, PA, Williams and Wilkins, 1992.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, pp 400, 405, 407, 450.

Question 81

Which of the following diseases has documented transmission by allograft tissue transplantation in the last 20 years?

Explanation

DISCUSSION: The only reported cases of HIV transmission with tissue transplantation occurred more than 20 years ago. The only reported cases of tuberculosis and hepatitis B occurred more than 50 years ago. The donor-associated clostridium infection occurred in 2001. The facility was not AATB-accredited (American Association of Tissue Banks) and the local A ATB facility refused the graft. It is necessary for the surgeon using the allograft tissue to be aware of the current status of tissue regulation, and procurement and processing procedures.
REFERENCES: McAllister DR, Joyce MJ, Mann BJ, et al: Allograft update: The current status of tissue regulation, procurement, processing, and sterilization. Am J Sports Med 2007;35:2148-2158.
Safety of tissue transplants. American Association of Tissue Banks, 2006. Question 74
Which of the following types of intra-articular pathology is associated with lateral meniscal cysts?
Discoid meniscus
Posterolateral comer injury
Vertical meniscal tears
Middle third lateral meniscal tears
Popliteus tendon tears
DISCUSSION: Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition.
Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the
tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.
REFERENCES: Hulet C, Souquet D, Alexandre P, et al: Arthroscopic treatment of 105 lateral meniscal cysts with 5-year average follow-up. Arthroscopy 2004;20:831-836.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part I. Macroscopic and histologic findings. Clin Orthop
Relat Res 1980;146:289-300.
Ferrer-Roca O, Vilalta C: Lesions of the meniscus: Part II. Horizontal cleavages and lateral cysts. Clin Orthop Relat Res 1980:146:301-307.

Question 82

A 16-year-old female with adolescent idiopathic scoliosis undergoes posterior spinal fusion with instrumentation. The thoracic pedicle screws were placed using a tap 1 mm smaller than the screw diameter and a straightforward trajectory that runs parallel to the superior endplate. This techniques allows for which of the following: Review Topic

Explanation

Straightforward trajectory when placing pedicle screws in addition to prior tapping 1mm smaller than the screw diameter increase the maximal insertional torque and resistance to screw pullout.
Contemporary segmental pedicle screw placement used in the treatment of scoliosis deformity offer significantly higher screw pullout and deformity correction than prior hook and wire constructs. Additionally, screw insertional torque has been found in numerous studies to correlate with resistance to screw pullout. Several factors have been found to increase maximum screw insertional torque, including tapping 1mm smaller than the screw diameter and using the straightforward trajectory. It is important to note that while undertapping makes for a stronger screw, there are some studies that suggest not tapping at all makes for an even stronger screw.
Lehman et al. performed a biomechanical study evaluating maximum insertional torque when tapping line to line, undertapping by 0.5mm, and undertapping by 1mm in 34 fresh frozen cadavers. They found undertapping the thoracic pedicle by 1mm increased maximum insertional torque by 47% when compared to undertapping by 0.5mm and by 93% when compared to line to line tapping.
Kuklo et al. performed a biomechanical study on thirty cadavers using the straightforward technique (sagittal trajectory of the screws parallels the superior endplate of the vertebral body) versus anatomic trajectory (22 degrees in the cephalo-caudad direction in the sagittal plane). They found maximum insertional torque to be

Question 83

This image represents the end stage of an uncompensated rotator cuff tear.

Explanation

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187. View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 84

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function. A pathognomonic radiographic feature of this injury is a

Explanation

Discussion: Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficulty
Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.
Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Question 85

A 50-year-old competitive tennis player sustained a shoulder dislocation after falling on his outstretched arm 3 weeks ago. He now reports that he has regained motion but continues to have painful elevation and weakness in external rotation. A subacromial cortisone injection provided 3 weeks of relief, but the pain has returned. Which of the following studies will best aid in diagnosis?

Explanation

DISCUSSION: Based on these findings, the most likely diagnosis is a rotator cuff injury and probable tear; therefore, MRI is the study of choice. CT is preferred for articular fractures. A bone scan is nonspecific and can identify inflammation or occult fracture. Joint aspiration is not likely to identify an effusion. Physical therapy and a functional capacity examination are used to identify weakness during recovery prior to a return to work or sports.
REFERENCES: Hawkins RJ, Bell RH, Hawkins RH, Koppert GJ: Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-195.
Matsen FA III, Thomas SC, Rockwood CA: Anterior glenohumeral instability, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 526-622.

Question 86

What is the most important surface geometry design parameter associated with decreased contact stress and wear reduction in total knee prostheses?

Explanation

The analysis of contact stress as a function of thickness of the polyethylene insert for tibial components has shown that a thickness of more than 8-10 millimeters should be maintained when possible. The contact stress in the tibial components was reduced most when the articulating surfaces were more conforming in the medial-lateral direction. Contact stresses were much less sensitive to changes in geometry in the anterior-posterior direction.

Question 87

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

Explanation

DISCUSSION
This patient sustained an eccentric contracture (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors have the highest
potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed.
The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared to the 2-incision technique. The most troubling complication for most surgeons is the development of a PIN palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABC nerve injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button.
Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The EIP is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC followed by the ECU, EDQ, and, finally, the EIP.
RESPONSES FOR QUESTIONS 26 THROUGH 27
Anterior tibial artery
Posterior tibial artery
Superficial peroneal nerve
Deep peroneal nerve
Match the neurovascular structure at risk (listed above) with the compartment undergoing fasciotomy (listed below).

Question 88

What medication has been shown to decrease osteolysis after total joint replacement surgery?

Explanation

Bisphosphonates have been shown to decrease osteolysis after total joint replacement surgery.
Aseptic loosening and osteolysis are the primary causes of implant failure in total
joint arthroplasty. Early findings indicate that bisphosphonates upregulate bone morphogenetic protein-2 production and stimulate new bone formation, leading to decreased osteolysis in total joint replacement surgery. While further investigation is required, bisphosphonates may play a future role in improving the long-term duration of joint arthroplasties.
Shanabhag et al. reviewed the use of bisphosphonates and reported that they had the potential to enhance bone ingrowth into implant porosities, prevent bone resorption under adverse conditions, and dramatically extend the long-term durability of joint arthroplasties. They recommended further investigation into the subclasses to determine which ones are most beneficial.
Arabmotlagh el al. performed a prospective study on use of alendronate after total hip arthroplasty. They reported that the alendronate-treated patients had significantly less periprosthetic bone loss on DXA scans after 6 years.
Illustration A shows evidence of osteolysis (arrows) around a total hip arthroplasty. Incorrect Answers:
2-5: These medication classes do not decrease osteolysis after total joint arthroplasty.

Question 89

A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. The patient is at greatest risk of developing which of the following conditions as a result of this malunion?

Explanation

CORRECT
DISCUSSION: A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

Question 90

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Explanation

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,

pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 91

A 50-year-old man undergoes revision total knee arthroplasty (TKA). The tibial component shown in Figure 153 was retrieved at the time of revision. The wear damage demonstrated on the backside of the tibial component is most likely related to which wear mechanism(s)?

Explanation

DISCUSSION
Pitting and delamination seen in tibial component retrievals on the bearing surface of a TKA is related to fatigue wear. Backside wear is shown in the photograph; this is where the lot numbers usually are present, but now they are not distinguishable because of backside wear. This wear mechanism is attributable to adhesive and abrasive wear. The nanometer-size particles created by this wear mechanism account for the higher prevalence of osteolysis associated with modular tibial components.
CLINICAL SITUATION FOR QUESTIONS 154 AND 155
Five weeks ago, an 82-year-old man underwent revision total knee arthroplasty (TKA). Three weeks after surgery he had a dental cleaning. The patient now reports 2 days of worsening pain following a long physical therapy session. His C-reactive protein (CRP) level is 15.0 mg/L (reference range, 0.08-3.1 mg/L). Upon examination, there is no drainage and slight effusion, and he has a passive range of motion to 110 degrees. Radiographs are unremarkable.

Question 92

In the first dorsal compartment of the wrist, what tendon most frequently contains multiple slips?

Explanation

DISCUSSION: The first extensor compartment of the wrist typically contains a single extensor pollicis brevis tendon and the abductor pollicis longus tendon that nearly always has multiple tendon slips. The extensor pollicis brevis tendon is frequently found to be separated from the slips of the abductor pollicis longus tendon by an intracompartmental septum. During surgery, this septum must be divided to complete the release of the compartment.
REFERENCES: Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM: Anatomical variations in the first extensor compartment of the wrist: A clinical and anatomical study. J Bone Joint Surg Am 1986;68:923-926.
Minamikawa Y, Peimer CA, Cox WL, Sherwin FS: DeQuervain’s syndrome: Surgical and anatomical studies of the fibro-osseous canal. Orthopedics 1991;14:545-549.

Question 93

A 42-year-old man has increasing pain and, to a lesser extent, some occasional left knee instability. Several years earlier he sustained a noncontact twisting injury to his knee. He had some initial soreness and pain but was able to resume his normal activities while avoiding sports. On examination, the patient has medial joint line pain, a grade 2+ Lachman, and a slight varus thrust. His radiographs reveal mild-to-moderate medial compartment osteoarthritis with varus alignment. What surgical treatment strategy likely will alleviate his pain? Review Topic

Explanation

This patient had a previous anterior cruciate ligament (ACL) and posterolateral complex injury. With chronic instability and osteoarthritis, the best option is HTO with a decrease in the tibial slope to reduce anterior laxity. Distal femoral osteotomy is better suited to address valgus malalignment. The lateral closing-wedge osteotomy would not allow for adequate correction of the tibial slope. Unicompartmental knee replacement is not indicated when there is ligament instability. If the patient continues to experience instability following correction of the varus malalignment, reconstruction of the ACL and posterolateral corner would be appropriate at that time.

Question 94

A nonambulatory verbal 6-year-old child with spastic quadriplegic cerebral palsy has progressive bilateral hip subluxation of more than 50%. There is no pain with range of motion, but abduction is limited to 20 degrees maximum. An AP radiograph is seen in Figure 34. Management should consist of

Explanation

DISCUSSION: The natural history of the patient’s hips, if left untreated, is gradual progression to dislocation. To prevent future pain, prevention of dislocation is often helpful. The patient is too old for soft-tissue releases alone. Therefore, the treatment of choice is medial release of both hips to obtain 45 degrees or better of hip abduction in conjunction with psoas tenotomy and bilateral femoral varus osteotomies.
REFERENCES: Presedo A, Oh CW, Dabney KY, et al: Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am 2005;87:832-841.
Miller F, Bagg MR: Age and migration percentage as risk factors for progression in spastic hip disease. Dev Med Child Neurol 1995;37:449-455.

Question 95

Figures 8a through 8d show the radiographs and CT scans of a 14-year-old girl who has a painful, rigid planovalgus foot. Management consisting of arch supports and anti-inflammatory drugs failed to provide relief. A below-knee walking cast resulted in pain resolution, but she now reports that the pain has recurred. Management should now consist of

Explanation

DISCUSSION: Tarsal coalitions commonly present in the preadolescent age group as a rigid, planovalgus foot. Small coalitions of the calcaneonavicular joint or the middle facet of the talocalcaneal joint can be excised with interposition of fat or muscle tissue. Isolated calcaneocuboid joint coalitions are very rare. This patient has an associated large talocalcaneal coalition; therefore, resection is contraindicated. Surgery is warranted after failure of nonsurgical management, and because of the involvement of two joints, the only viable option for the severely symptomatic foot is triple arthrodesis.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Olney BW: Tarsal coalition, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 169-181.

Question 96

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Explanation

Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver? Review Topic

Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 97

Figures below depict the AP and lateral radiographs obtained from a 64-year-old man with long-standing right knee osteoarthritis and pain that is unresponsive to nonsurgical treatment. The patient undergoes navigated cruciate-retaining right total knee arthroplasty. After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office reporting continued pain 2 years after surgery. He describes instability, particularly when descending stairs. On examination, range of motion of 0° to 120° is observed, with no extensor lag. Slope of the tibial component is 7°. The knee is stable to varus and valgus stress in extension, but flexion instability is present in both the anterior-posterior direction and the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection work-up is negative. What is the most appropriate surgical intervention at this time?

Explanation

DISCUSSION:
The patient’s symptoms at follow-up—pain, swelling, and difficulty descending stairs—suggest knee flexion instability. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant (depending on the condition of the ligaments) likely is needed to address his symptoms. The difference in extension stability and flexion stability makes polyethylene exchange a poor option. A constrained rotating hinge design is not necessary. Repeat use of a PCL-retaining insert is not recommended. Tibial and femoral revision both are required. Correction of excessive slope will be attained with tibial revision, femoral component revision is required to convert to a PCL-substituting design. There is also an opportunity to increase posterior condylar offset if needed.

Question 98

What is the most common causative bacteria in septic arthritis in children?

Explanation

DISCUSSION: The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 2109.
Jackson MA, Nelson JD: Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 1982;2:313-323.

Question 99

The dorsal (Thompson) approach to the proximal forearm uses which of the following intermuscular intervals?

Explanation

DISCUSSION: The Thompson posterior approach is used in treatment of fractures of the proximal radius. Dissection is carried out through the interval between the extensor carpi radialis brevis (radial nerve) and the extensor digitorum communis (posterior interosseous nerve). To identify this interval, the forearm is pronated and the mobile lateral wad of muscles (the ulnar-most belly is the extensor carpi radialis brevis) is grasped with the thumb and finger and pulled from the much less mobile mass of the extensor digitorum communis. The furrow created is marked with a skin marker for subsequent skin incision. The skin incision follows a line from the lateral epicondyle of the humerus to a point corresponding to the middle of the posterior aspect of the wrist. Distally, the intermuscular plane is between the extensor carpi radialis brevis and the extensor pollicis longus.
REFERENCES: Crenshaw AH Jr: Surgical techniques and approaches, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 128-129.
Hoppenfeld S, deBoer P: Posterior approach to the radius, in Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, pp 136-146.
Thompson JE: Anatomical methods of approach in operations on the long bones of the extremities. Ann Surg 1918;68:309-316.

Question 100

A 75-year-old woman has a 1-year history of right hip pain and a right total hip arthroplasty (THA) performed in 1999. Her left THA, performed in 2002, is asymptomatic. Plain radiographs show that all of the components appear well fixed and in good position. There is evidence of eccentric polyethylene wear of the right hip with focal osteolysis of the calcar and great trochanter (with none of these findings on the left hip). What is the most likely explanation for her right hip pain?

Explanation

DISCUSSION
This patient likely has 1 conventional polyethylene hip (1999) and 1 hip with highly cross-linked polyethylene (HXLPE) (2002); most centers transitioned to HXLPE around 2001 to 2002. This explains the clear difference in the clinical and radiographic performance of the 2 hips during the second decade. There is clear evidence of decreased wear and osteolysis and clinical benefits (ie, decreased revision rate) during the second decade following the introduction of HXLPE for THA. Acute infection is unlikely considering the chronicity of symptoms. The radiographs show no obvious evidence of cup loosening. A pseudotumor attributable to trunnionosis, while reported, remains an infrequent clinical issue.

Full Question & Answer Text (for Search Engines)

Question 1:

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Options:

Upper third
Junction of upper third and middle third
Middle third
Junction of middle third and lower third
Lower third

Correct Answer: Lower third

Explanation:

Question 2:

Options:

aspiration of the left hip.
application of a Pavlik harness.
a gallium scan.
an MRI scan of the spine.
modified Bryant traction.

Correct Answer: aspiration of the left hip.

Explanation:

Question 3:

A 67-year-old woman is seen in the emergency department after falling at home. Radiographs before and after treatment are shown in Figures 49a and

Options:

Axillary nerve palsy
Spinal accessory nerve palsy
Deltoid avulsion
Rotator cuff tear
Unreduced posterior glenohumeral dislocation

Correct Answer: Rotator cuff tear

Explanation:

Question 4:

Options:

Kingella kingae
Group A beta-hemolytic streptococcus
Group B streptococcus
Staphylococcus epidermidis
Staphylococcus aureus

Correct Answer: Group A beta-hemolytic streptococcus

Explanation:

DISCUSSION: The most common bacterial etiologic agent following varicella is group A beta-hemolytic streptococcus. The other organisms are much less common. Staphylococcus aureus is the most common bone infection organism. Staphylococcus epidermidis is increasingly a bone infection organism. Group B streptococcus occurs more commonly in newborns. Kingella kingae is a common joint pathogen but is not as common following varicella.
REFERENCES: Schreck P, Schreck P, Bradley J, et al: Musculoskeletal complications of varicella. J Bone Joint Surg Am 1996;78:1713-1719.
Mills WJ, Mosca VS, Nizet V: Orthopaedic manifestations of invasive group A streptococcal infections complicating primary varicella. J Pediatr Orthop 1996;16:522-528.

Question 5:

Options:

Eye patch and ophthalmology evaluation in 2 days
Fluorescein eye stain
Emergent CT
High-dose systemic steroids
Observation

Correct Answer: Emergent CT

Explanation:

Question 6:

Which examination finding points toward a brachial plexus injury rather than root avulsion?

Options:

Winging of the scapula
Intact rhomboid function
A biceps with 0/5 strength
An ipsilateral clavicle fracture

Correct Answer: Intact rhomboid function

Explanation:

Question 7:

Figure 92 is the radiograph of a 45-year-old man who was thrown from his horse and now reports groin pain. Which of the following is the most common long-term sequelae of this injury?

Options:

Gait abnormality
Sexual dysfunction
Chronic low back pain
Quadriceps weakness
Posttraumatic osteoarthritis

Correct Answer: Sexual dysfunction

Explanation:

Question 8:

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Options:

Axillary nerve injury
Anterior dislocation
Extension of a chronic large rotator cuff tear
Suprascapular nerve entrapment from a ganglion cyst
Greater tuberosity avulsion

Correct Answer: Extension of a chronic large rotator cuff tear

Explanation:

Question 9:

Which of the following procedures is not part of the routine evaluation of a patient with suspected metastatic disease to bone?

Options:

Thorough history and physical examination
CBC count, electrolytes, and serum protein electrophoresis
Bone scan
CT of the brain
Radiograph and CT of the chest

Correct Answer: CT of the brain

Explanation:

Question 10:

Options:

Posterior tibial tendinitis
Osteoid osteoma
Posterior ankle impingement
Tibial stress fracture
Flexor hallucis longus tendinitis

Correct Answer: Tibial stress fracture

Explanation:

Question 11:

Options:

Age older than 40 years
Body mass index higher than 30
Tönnis grade of 2 or higher
Outer bridge grade of III or IV

Correct Answer: Tönnis grade of 2 or higher

Explanation:

Question 12:

Options:

Continued serial neurologic examinations
CT with a myelogram of the lumbar spine
Immediate surgical exploration and hematoma drainage
Electromyography of bilateral lower extremities
IV antibiotics for 24 hours, followed by surgical exploration if symptoms persist

Correct Answer: Immediate surgical exploration and hematoma drainage

Explanation:

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 13:

A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation?

Options:

He has a higher risk of rehospitalization
He has a higher chance of returning to work
He will have a higher overall SIP (Sickness Impact Profile) score
His psychosocial SIP score will improve with time
He will have a better SIP score if he did not complete high school

Correct Answer: He has a higher risk of rehospitalization

Explanation:

Question 14:

Options:

Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction followed by surgery after the ecchymosis has resolved

Correct Answer: Application of balanced traction followed by surgery after the ecchymosis has resolved

Explanation:

Question 15:

In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic

Options:

Legg-Calve-Perthes disease
Traumatic labral tear
Repetitive high-impact activity such as football
Femoroacetabular impingement
Hip injury resulting from a direct impact such as a knee hitting a dashboard

Correct Answer: Femoroacetabular impingement

Explanation:

Question 16:

What factor is associated with a higher risk of dislocation after total hip arthroplasty?

Options:

Male gender
Previous hip surgery
A direct lateral surgical approach
Metal-on-metal bearing surfaces

Correct Answer: Previous hip surgery

Explanation:

Question 17:

Options:

Growth arrest of the medial trochlear physis
Varus malunion of a supracondylar humeral fracture
Valgus malunion of a lateral condylar fracture
Posterior and lateral dislocation of the radial head
Osteonecrosis of the capitellum

Correct Answer: Varus malunion of a supracondylar humeral fracture

Explanation:

Question 18:

Options:

Tear of the plantar plate
Second MTP joint synovitis
Second metatarsal stress fracture
Flexor tendonitis

Correct Answer: Tear of the plantar plate

Explanation:

DISCUSSION
Lesser-toe plantar plate injuries are becoming increasingly recognized. Patients typically have an increase in pain, a positive Lachman test result upon examination, and deviation of the MTP joint. On radiograph, MTP subluxation can be appreciated. Nonsurgical treatment with a metatarsal pad may be attempted. Many patients who have surgery will have a partial or full tear of the plantar plate. The repair necessitates reinsertion of the plantar plate to the base of the proximal phalanx.
RECOMMENDED READINGS
Doty JF, Coughlin MJ, Weil L Jr, Nery C. Etiology and management of lesser toe metatarsophalangeal joint instability. Foot Ankle Clin. 2014 Sep;19(3):385-405. doi: 10.1016/j.fcl.2014.06.013. Epub 2014 Jul 10. PubMed PMID: 25129351.
View Abstract at
PubMed
Nery C, Coughlin MJ, Baumfeld D, Raduan FC, Mann TS, Catena F. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears. Foot Ankle Int. 2014 Sep;35(9):876-85. doi: 10.1177/1071100714539659. Epub 2014 Jun 23. PubMed PMID:

Question 19:

Options:

Bracing
Posterior spinal fusion of only the right thoracic curve
Posterior spinal fusion from T2-L4
Vertebral body stapling to halt progression of the curve
Anterior and posterior spinal fusion

Correct Answer: Posterior spinal fusion of only the right thoracic curve

Explanation:

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and
14 • American Academy of Orthopaedic Surgeons
posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.
REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

Question 20:

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Options:

Type IIIB intra-articular distal tibia fracture
Type IIIB segmental midshaft tibia fracture
Type IIIB transverse midshaft tibia fracture
Type IIIB Schatzker I proximal tibia fracture
Type IIIB Schatzker IV proximal tibia fracture

Correct Answer: Type IIIB intra-articular distal tibia fracture

Explanation:

Question 21:

Figure 56 is the radiograph of an otherwise healthy 3-year-old boy who fell and sustained the isolated injury shown. What is the best treatment modality?

Options:

Elastic intramedullary nailing
Submuscular plating
Early hip spica casting
Traction as definitive treatment

Correct Answer: Early hip spica casting

Explanation:

Question 22:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 23:

Options:

host chondrocytes in the articular cartilage.
subchondral revascularization and fragmentation, without evidence of cartilage degeneration.
an articular surface covered with a pannus of synovial tissue.
radiographically normal thickness of the articular surface, with evidence of cellular debris in the lacuna.
severe degenerative changes in the articular cartilage surface with complete loss of the tidemark.

Correct Answer: radiographically normal thickness of the articular surface, with evidence of cellular debris in the lacuna.

Explanation:

DISCUSSION: Osteoarticular allografts are devoid of host chondrocytes but do contain “mummified” cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact.
REFERENCES: Enneking WF, Campanacci DA: Retrieved human allografts:
A clinicopathological study. J Bone Joint Surg Am 2001;83:971-986.
Enneking WF, Mindell ER: Observations on massive retrieved human allografts.
J Bone Joint Surg Am 1991;73:1123-1142.

Question 24:

Plate fixation of olecranon fractures is recommended over tension band wire fixation when

Options:

the fracture is proximal and only involves the olecranon tip.
the fracture is transverse.
the fracture is comminuted.
the fracture is widely displaced.
there is associated osteoporosis.

Correct Answer: the fracture is comminuted.

Explanation:

Question 25:

Options:

Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction
Decreased pain following surgery; sensory deficits and bladder function are not likely to improve
No change in her symptoms following surgery
Complete resolution of pain and will have normal sensation and bladder function following surgery
Improvement in her pain and complete return of bladder function following surgery; sensation may not return

Correct Answer: Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction

Explanation:

Question 26:

Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?

Options:

Respiratory depression
Increased salivary secretion
Hypertension
Emergence phenomena
Cerebral vasoconstriction

Correct Answer: Increased salivary secretion

Explanation:

Question 27:

- A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include

Options:

observation and exercises
bracing with a thoracolumbar orthosis
fusion of the posterior spine
fusion of the anterior spine
fusion of the anterior and posterior spine

Correct Answer: observation and exercises

Explanation:

Question 28:

Options:

Renal osteodystrophy
Diastrophic dysplasia
Metaphyseal dysplasia
Osteogenesis imperfecta
Fibrous dysplasia

Correct Answer: Renal osteodystrophy

Explanation:

Question 29:

Options:

Staphylococcus epidermidis
Methicillin-resistant Staphylococcus aureus
Pseudomonas aeruginosa
Propionibacterium acnes
Clostridium tetani

Correct Answer: Propionibacterium acnes

Explanation:

Question 30:

Options:

Primary osteoarthritis
Post-capsulorrhaphy arthropathy
Post-traumatic arthritis
Arthritis from poor placement of coracoid transfer
Avascular necrosis

Correct Answer: Primary osteoarthritis

Explanation:

Question 31:

Options:

loss of active thumb interphalangeal (IP) flexion.
distal radioulnar joint instability.
avascular necrosis of the capitate.
ulnar carpal translocation.

Correct Answer: ulnar carpal translocation.

Explanation:

Question 32:

Options:

Emergent exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30% and sequential neurovascular examinations
Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30%, continued administration of enoxaparin, and sequential neurovascular examinations
Placement of a temporary vena cava filter and exploration of the sciatic nerve

Correct Answer: Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve

Explanation:

Question 33:

Options:

Repeat closed reduction and splinting under anesthesia to achieve absolute stability
Closed reduction and temporary transarticular fixation using 1.6 mm Kirschner-wires to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve relative stability
Temporary external fixation of the ankle to achieve relative stability

Correct Answer: Definitive open reduction and internal fixation of the ankle to achieve absolute stability

Explanation:

Question 34:

Options:

normal sexual function and normal vaginal childbirth.
sexual dysfunction (dyspareunia) and normal vaginal childbirth.
normal sexual function and caesarean section childbirth.
sexual dysfunction (dyspareunia) and caesarean section childbirth.
normal sexual function and caesarean section childbirth until hardware removal.

Correct Answer: sexual dysfunction (dyspareunia) and caesarean section childbirth.

Explanation:

DISCUSSION: Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
REFERENCES: Copeland CE, Bosse MJ, McCarthy ML et al: Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 1997;11:73-81.
Wright JL, Nathans AB, Rivara FP, et al: Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. J Urol 2006;176:1540-1545.

Question 35:

Options:

Anterior dislocation of the shoulder
Salter-Harris type I fracture of the proximal humeral physis
Rupture of the subscapularis tendon
Sprain of the acromioclavicular joint
Fracture of the glenoid neck

Correct Answer: Salter-Harris type I fracture of the proximal humeral physis

Explanation:

Question 36:

Options:

Incomplete C5 spinal cord injury
Complete C5 spinal cord injury
Complete C6 spinal cord injury
Central spinal cord injury
Brown-STquard syndrome

Correct Answer: Complete C5 spinal cord injury

Explanation:

Question 37:

Options:

Physical therapy
Arthroscopic synovectomy
Tibial insert revision
Femoral component revision

Correct Answer: Arthroscopic synovectomy

Explanation:

Question 38:

Which of the following is considered a specific advantage of using COX-2 inhibitors over COX-1 inhibitors?

Options:

Conversion of arachidonic acid to prostaglandins
Higher degree of efficacy
Does not affect platelet function and can be used during the perioperative period
Can be used in patients with congestive heart failure and renal disease
High levels of COX-2 (cyclooxygenase) found in normal tissue

Correct Answer: Does not affect platelet function and can be used during the perioperative period

Explanation:

DISCUSSION: Inflammation is mediated through two isoforms of cyclooxygenase that convert arachidonic acid to prostaglandins. Selectivity, but not specificity, is one of the unique characteristics of this process that has been able to provide more protection from the effects of gastric mucosal alterations using the COX-2 selective inhibitors. The use of COX-1 selective inhibitors is associated with side effects such as ulcerative conditions and platelet interference, both of which have been difficult to control in the past until the advent of the COX-2 inhibitors. PGE
2
inhibition by COX-1 in the intestinal track can then be bypassed, thereby reducing ulceration complications associated with use of nonsteroidal anti-inflammatory drugs.
REFERENCES: Lane JM: Anti-inflammatory medications: Selective COX-2 inhibitors. J Am Acad Orthop Surg 2002;10:75-78.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000.

Question 39:

A 65-year-old woman has significant neck pain after falling and striking her head. A radiograph and sagittal CT scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Options:

Degenerative spondylolisthesis
Superior facet fracture
Inferior facet fracture
Perched unilateral facet dislocation
Bilateral facet dislocation

Correct Answer: Perched unilateral facet dislocation

Explanation:

Question 40:

Options:

Brachial plexus stretch injury
Cervical radiculopathy
Rotator cuff tendinitis
Anterior subluxation of the shoulder
Thoracic outlet syndrome

Correct Answer: Thoracic outlet syndrome

Explanation:

Question 41:

Options:

Application of a rigid collar and follow-up radiographs in 1 week
Gardner-Wells tongs and in-line traction
Hospital admission and frequent neurologic checks
Immobilization of the neck, followed by CT with reconstruction
Flexion-extension radiographs to evaluate for any occult instability

Correct Answer: Immobilization of the neck, followed by CT with reconstruction

Explanation:

DISCUSSION: A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine.
REFERENCES: Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998,
pp 724-727.
McDowell GS, Cammisa FP, Eismont FJ: Hyperextension injuries of the cervical spine, in Levine AM, Eismont FJ, Garfin SR, Zigler JE (eds): Spine Trauma. Philadelphia, PA,
WB Saunders, 1998, pp 372-374.

Question 42:

Options:

Cast removal and measurement of carpal canal pressure
Immediate carpal tunnel release and pinning of the fracture
Continued observation
Surgical reduction and pinning of the fracture
Electromyography/nerve conduction velocity studies

Correct Answer: Immediate carpal tunnel release and pinning of the fracture

Explanation:

Question 43:

Options:

No pharmacologic intervention is recommended at this time
Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours

Correct Answer: No pharmacologic intervention is recommended at this time

Explanation:

DISCUSSION: The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for
48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.
REFERENCES: Braken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.
Kwon BK, Tetzlaff W, Grauer JN, et al: Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451-464.

Question 44:

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Options:

Prior shoulder joint infection
Pseudoparalysis
Prior partial acromioplasty
Absent glenohumeral joint space narrowing
Axillary neuropathy

Correct Answer: Axillary neuropathy

Explanation:

Question 45:

Options:

Flexor pollicis longus rupture
Median nerve palsy
Ulnar nerve palsy
Anterior interosseous nerve palsy
Posterior interosseous nerve palsy

Correct Answer: Anterior interosseous nerve palsy

Explanation:

DISCUSSION: The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.
REFERENCES: Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome.
J Hand Surg Br 1992;17:510-512.
Seror P: Anterior interosseous nerve lesions: Clinical and electrophysiological features. J Bone Joint Surg Br 1996;78:238-241.

Question 46:

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Options:

Sustentaculum tali
Lateral process of the talus
Posterior process of the calcaneus
Os tibialis externum
Os trigonum

Correct Answer: Os trigonum

Explanation:

Question 47:

Options:

protected weight bearing and anti-inflammatory drugs.
core decompression of the femoral head.
vascularized free fibular grafting to the femoral head.
bipolar hemiarthroplasty of the hip.
total hip arthroplasty.

Correct Answer: protected weight bearing and anti-inflammatory drugs.

Explanation:

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck on STIR imaging, diagnostic of transient osteoporosis of the femoral head. This disease entity can be seen in middle-aged men, and should be treated nonsurgically. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip: A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 48:

Emergent management of acute tooth displacement (luxation) includes

Options:

delaying replantation until a dentist is present.
scrubbing the root of the tooth clean with hydrogen peroxide.
transporting the tooth in a carbonated beverage.
emergency root canal. §. immediate repositioning or replantation of the tooth.

Correct Answer: delaying replantation until a dentist is present.

Explanation:

Question 49:

Options:

hip and knee extension
hip flexion to 90, knee extension
hip internal rotation, knee flexion to 90
hip and knee flexion to 90
hip extension, knee flexion to 90

Correct Answer: hip and knee extension

Explanation:

Question 50:

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

Options:

Radioscaphocapitate
Scapholunate interosseous
Ulnotriquetral
Volar radioulnar
Deep proximal capitohamate

Correct Answer: Radioscaphocapitate

Explanation:

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.
REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy. Tech Hand Up Extrem Surg 1999;3:32-36.

Question 51:

Autosomal dominant

Options:

This patient has multiple hereditary exostoses. Widening of the metaphysis is characteristic of multiple hereditary exostoses. Large sessile osteochondromas arise from the metaphysis and a large osteochondroma arises from the medial metaphysis with a characteristic cartilaginous cap. The computed tomography scan shows the widening and abnormal tubulation of the bone.
No evidence of malignancy exists in this large osteochondroma. The cartilage cap is regular with no areas of bone destruction. One should also look for a soft tissue mass, which often shows areas of focal calcifications. No soft tissue masses are present in this patient.
It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Correct Answer: It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Explanation:

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following tumor suppressor genes is most likely involved:

Question 52:

Options:

10%
25%
50%
75%
Greater than 75%

Correct Answer: Greater than 75%

Explanation:

Question 53:

Options:

rest and a sling followed by a gradual return to activities.
physical therapy and extension-block bracing.
repair of the biceps tendon to the brachialis muscle.
repair of the common flexor origin.
anatomic repair of the distal biceps tendon.

Correct Answer: anatomic repair of the distal biceps tendon.

Explanation:

Question 54:

Options:

hallux metatarsophalangeal arthrodesis.
custom orthotics.
Chevron osteotomy with second toe correction.
Keller resection arthroplasty with second toe correction.
proximal metatarsal osteotomy with second toe correction.

Correct Answer: proximal metatarsal osteotomy with second toe correction.

Explanation:

Question 55:

03 5.

Options:

Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:
increase in bone resorption with increase in the number and size of osteoclasts, AKA the “hot” phase.
Rapid increase in osteoblast activity and new bone formation, AKA the “intermediate” phase
Decrease in both osteoclastic and osteoblastic activity, AKA “cold” phase

Correct Answer: Second only to osteoperosis as the most common metabolic bone disease, Paget’s disease is most often asymptomatic and diagnosed incidentally on routine x-rays. There three distinct histologic phases:

Explanation:

Question 56:

- A patient who had previously undergone a salvage pelvic (Chiari) osteotomy now requires a total hip arthroplasty. The most frequent complication of this procedure is

Options:

fracture of the acetabulum
protrusion of the acetabulum
inadequate inferior coverage
inadequate superior coverage
inadequate anterior and posterior coverage

Correct Answer: inadequate anterior and posterior coverage

Explanation:

Question 57:

Which of the following best describes heat stroke?

Options:

Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature
A condition involving painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride
Hypernatremia in poorly conditioned athletes, manifested by thirst and oliguria with a core temperature of less than 102.2 degrees F (39 degrees C)
Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function
A transient condition that responds to glucose administration

Correct Answer: Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function

Explanation:

Question 58:

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Options:

Valgus laxity at 30 degrees of knee flexion
Varus laxity at 30 degrees of knee flexion
Posterior drawer
Pivot shift
Patellar apprehension

Correct Answer: Pivot shift

Explanation:

DISCUSSION: The T
2
-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T
2
-weighted images and diminished signal intensity on T
r
weighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 59:

Options:

Anti-inflammatory medication and gradual return to activity
Admit for pain control and repeat neurologic examination
Thoracolumbosacral orthosis
Multi-level posterior spinal instrumentation and fusion
Anterior corpectomy and fusion

Correct Answer: Anterior corpectomy and fusion

Explanation:

Question 60:

Options:

long leg casting in 30 degrees of flexion for 6 weeks.
a long leg cast in full extension for 6 weeks.
knee arthroscopy to rule out internal derangement.
physical therapy for range of motion and quadriceps strengthening.
open reduction and internal fixation.

Correct Answer: a long leg cast in full extension for 6 weeks.

Explanation:

Question 61:

Options:

Oral cephalosporin
IV cephalexin and dressing changes
Betadine dressing and a short leg cast
Debridement of the wound and removal of the hardware
Debridement of the wound and maintenance of the hardware

Correct Answer: Debridement of the wound and maintenance of the hardware

Explanation:

Question 62:

Options:

bridging external callus along the allograft and perpendicular callus at the junction site.
direct osteonal penetration of the allograft with haversian remodeling.
complete incorporation of the allograft with obliteration of the host allograft junction site.
fibrovascular invasion with absence of callus formation.
gap formation with resorption of the allograft surface.

Correct Answer: bridging external callus along the allograft and perpendicular callus at the junction site.

Explanation:

Question 63:

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Options:

a Pavlik harness.
observation.
closed reduction and a spica cast.
open reduction and femoral shortening.
open reduction.

Correct Answer: open reduction.

Explanation:

Question 64:

Which of the following actions best enhances performance when an athlete is participating in a 10K race?

Options:

Load up on carbohydrates prior to the race.
Hydrate adequately prior to the race.
Replace fluid losses during the race.
Replace calories burned during the race.
Replace electrolytes lost during the race.

Correct Answer: Hydrate adequately prior to the race.

Explanation:

Question 65:

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Options:

Level of the fibular fracture
Lauge-Hansen fracture class
Intraoperative stress testing
Widening of the medial clear space
Talar dislocation

Correct Answer: Intraoperative stress testing

Explanation:

Question 66:

Options:

disruption of the sympathetic nerves during anterior lumbar exposure.
traction on the parasympathetic nerve at the L4-5 level.
not related to the surgical dissection.
injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level.
sexual dysfunction secondary to retrograde ejaculation.

Correct Answer: not related to the surgical dissection.

Explanation:

Question 67:

A 25 year-old-male sustains a closed injury shown in Figure A. If a tibial intramedullary nail is placed with the starting points shown (arrows), what subsequent alignment will occur?

Options:

Neutral
Varus, apex anterior
Varus, apex posterior
Valgus, apex anterior
Valgus, apex posterior

Correct Answer: Neutral

Explanation:

Question 68:

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Options:

Right-sided unstable intertrochanteric fracture
Left-sided unstable intertrochanteric fracture
Left-sided stable intertrochanteric fracture
Right-sided stable intertrochanteric fracture
All unstable intertrochanteric fractures

Correct Answer: Right-sided unstable intertrochanteric fracture

Explanation:

Question 69:

Options:

C5-C7 nerve roots; upper/middle trunks; anterior division; lateral cord
C5-C6 nerve roots; upper trunk; posterior division; posterior cord
C5-C6 nerve roots; upper trunk
C5-C7 nerve roots
C8-T1 nerve root; lower trunk; anterior division; medial cord

Correct Answer: C8-T1 nerve root; lower trunk; anterior division; medial cord

Explanation:

Question 70:

The dominant arterial blood supply to the patella enters at which anatomical location?

Options:

Proximal pole
Mid-lateral
Mid-medial
Directly anterior
Distal pole

Correct Answer: Proximal pole

Explanation:

Question 71:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 72:

Which factor increases the success rate associated with all-inside lateral meniscal repair?

Options:

Concomitant anterior cruciate ligament (ACL) reconstruction
Concomitant medial meniscus repair
Older patient age
Varus knee alignment

Correct Answer: Concomitant anterior cruciate ligament (ACL) reconstruction

Explanation:

Question 73:

Options:

HLA-B27
Prostate-specific antigen
Rheumatoid factor
Antinuclear antibody
Serum protein electrophoresis

Correct Answer: HLA-B27

Explanation:

Question 74:

Options:

4 mm of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph
Intact anterior cruciate ligament on MRI and physical examination
Recurrent effusions
Flattening of the femoral condyles
Healed high tibial osteotomy

Correct Answer: Flattening of the femoral condyles

Explanation:

Question 75:

Options:

Restrict fluid intake 2 hours before the start of the race to avoid abdominal cramping.
Drink low osmolality (less than 10%) solutions before, during, and after the race.
Drink fruit juice, such as orange juice, instead of water to replenish essential carbohydrates.
Drink high osmolality (greater than 10%) solutions before and during the race and low osmolality solutions after the race.
Avoid the use of glucose polymers because they slow down gastric emptying and may lead to abdominal cramping.

Correct Answer: Drink low osmolality (less than 10%) solutions before, during, and after the race.

Explanation:

Question 76:

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Options:

Central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome
Central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome
Brown-Sequard syndrome, anterior cord syndrome, central cord syndrome
Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome
Anterior cord syndrome, central cord syndrome, Brown-Sequard syndrome

Correct Answer: Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome

Explanation:

Question 77:

Options:

Discontinue use of the soft collar and encourage range of motion
Semi-rigid collar immobilization for 6 to 8 weeks
Surgical stabilization
Halo skeletal fixation
Outpatient physical therapy with isometric neck exercises

Correct Answer: Surgical stabilization

Explanation:

DISCUSSION: Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
REFERENCES: Findlay JM: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;39:210.
Dickman CA, Mamourian A, Sonntag VK, et al: Magnetic resonance imaging of the transverse atlantal ligament for the evaluation of atlantoaxial instability. J Neurosurgery 1991;75:221-227.

Question 78:

Options:

Joint stiffness
Cold intolerance
Decreased sweating
Osteopenia
Disproportionate pain

Correct Answer: Disproportionate pain

Explanation:

Question 79:

In the preoperative planning of revision acetabular reconstruction, the surgeon should identify significant posterior column deficiency by noting which of the following radiographic features?

Options:

Excessive vertical position of the acetabular component
Medial displacement of the hip center to the ilioischial line
Visible wear of the polyethylene articulation
Osteolysis in the ischium
Superior migration of 1 cm

Correct Answer: Osteolysis in the ischium

Explanation:

Question 80:

Based on the diagram shown in Figure 16, what muscle derives its innervation from the nerve identified by the letter “A”?

Options:

Pectoralis minor
Teres minor
Subclavius
Brachialis
Supraspinatus

Correct Answer: Teres minor

Explanation:

Question 81:

Which of the following diseases has documented transmission by allograft tissue transplantation in the last 20 years?

Options:

Tuberculosis
Hepatitis B
HIV
West Nile virus
Clostridium

Correct Answer: West Nile virus

Explanation:

Question 82:

Options:

Anatomic placement of the screws.
Increased depth insertion of the screws.
Increased maximal insertional torque.
Decreased resistance to screw pullout.
Decreased stability of the construct.

Correct Answer: Increased maximal insertional torque.

Explanation:

Question 83:

This image represents the end stage of an uncompensated rotator cuff tear.

Options:

Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.
Figure 59b is the radiograph of a 45-year-old man with acromiohumeral distance equal to 7 mm. He is able to actively raise his arm above shoulder level, has lateral arm pain,
and abduction and external rotation weakness. 56
Figures 59c and 59d are the radiographs of a 72-year-old man with night pain and reduced range of motion.

Correct Answer: Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.

Explanation:

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187.
View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 84:

Options:

radiocapitellar joint dislocation.
fat pad sign.
proximal radioulnar joint dislocation.
double arc sign.

Correct Answer: double arc sign.

Explanation:

Question 85:

Options:

CT
Limited bone scan
MRI
Joint aspiration
Functional capacity examination

Correct Answer: MRI

Explanation:

Question 86:

- What is the most important surface geometry design parameter associated with decreased contact stress and wear reduction in total knee prostheses?

Options:

Unrestrained roll-back
Unrestrained rotational conformity
Medial-Lateral conformity
Anteroposterior conformity in flexion
Anteroposterior conformity in extension

Correct Answer: Medial-Lateral conformity

Explanation:

Question 87:

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

Options:

Extensor indicis proprius (EIP)
Extensor digiti quinti (EDQ)
Extensor digitorum communis (EDC)
Extensor carpi ulnaris (ECU)

Correct Answer: Extensor indicis proprius (EIP)

Explanation:

Question 88:

What medication has been shown to decrease osteolysis after total joint replacement surgery?

Options:

Bisphosphonates
NSAIDs
TNF-alpha inhibitors
Calcium and vitamin D supplementation
BMP-7

Correct Answer: Bisphosphonates

Explanation:

Question 89:

Options:

Degenerative lumbar spine changes
Ipsilateral ankle pain and stiffness
Ipsilateral hip joint degenerative changes
Contralateral hip joint degenerative changes
Ipsilateral medial knee degenerative changes

Correct Answer: Degenerative lumbar spine changes

Explanation:

CORRECT
DISCUSSION: A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

Question 90:

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Options:

Fractures of the lower extremities
Paroxysmal hypertension
Infection
Epidural hematoma
Gastrointestinal bleeding

Correct Answer: Epidural hematoma

Explanation:

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,
pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 91:

Options:

Abrasive wear
Fatigue wear
Adhesive wear
Adhesive and abrasive wear

Correct Answer: Adhesive and abrasive wear

Explanation:

Question 92:

In the first dorsal compartment of the wrist, what tendon most frequently contains multiple slips?

Options:

Extensor pollicis longus
Extensor pollicis brevis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Abductor pollicis longus

Correct Answer: Abductor pollicis longus

Explanation:

Question 93:

Options:

Distal femoral osteotomy
Unicompartmental knee replacement
High tibial osteotomy (HTO), lateral closing wedge
HTO, medial opening wedge with decreased tibial slope

Correct Answer: HTO, medial opening wedge with decreased tibial slope

Explanation:

Question 94:

Options:

percutaneous bilateral adductor tenotomy.
oral baclofen.
phenol injection into the obturator nerve.
open adductor tenotomy with neurectomy of the anterior branch of the obturator nerve.
open adductor tenotomy with release of the iliopsoas and bilateral proximal femoral varus derotation osteotomy.

Correct Answer: open adductor tenotomy with release of the iliopsoas and bilateral proximal femoral varus derotation osteotomy.

Explanation:

DISCUSSION: The natural history of the patient’s hips, if left untreated, is gradual progression to dislocation. To prevent future pain, prevention of dislocation is often helpful. The patient is too old for soft-tissue releases alone. Therefore, the treatment of choice is medial release of both hips to obtain 45 degrees or better of hip abduction in conjunction with psoas tenotomy and bilateral femoral varus osteotomies.
REFERENCES: Presedo A, Oh CW, Dabney KY, et al: Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am 2005;87:832-841.
Miller F, Bagg MR: Age and migration percentage as risk factors for progression in spastic hip disease. Dev Med Child Neurol 1995;37:449-455.

Question 95:

Options:

custom orthotics.
a below-knee non-weight-bearing cast.
exploration and resection of the calcaneocuboid joint.
exploration and resection of the talocalcaneal joint.
triple arthrodesis.

Correct Answer: triple arthrodesis.

Explanation:

Question 96:

Figure 13 is the photograph of 18-month-old triplets with a lower-limb condition. What is the best initial treatment? Review Topic

Options:

Vitamin D supplementation and serum level monitoring
Mechanical axis alignment measurements on serial standing knee radiographs
Genetic testing and counseling for short-stature syndrome
Observation and clinical follow-up.

Correct Answer: Mechanical axis alignment measurements on serial standing knee radiographs

Explanation:

These triplets exhibit genu varum and internal tibial torsion that can be part of normal development. Fetal packing is the likely major contributing cause for these triplets, however. Observation and follow-up will be sufficient. Bowing and torsion can be clinical features of vitamin D deficiency, Blount disease, and short-stature syndromes, but these are not the most likely diagnoses. Radiographic diagnosis of Blount disease may not be accurate at this age.
(SBQ13PE.56) A 22-month-old female is hospitalized with a fever and malaise. She is found to be bacteremic, and blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA). During her hospitalization, the pediatrician notices her arm is slightly swollen and appears painful to use. MRI is obtained and demonstrated in figure A. Which feature of the MRI suggests the need for surgical management?
Review Topic
Brodie's Abscess
Osteomyelitis of the humeral metaphysis
Subperiosteal abscess of the humerus
Presence of subcutaneous air
High risk of proximal humeral growth arrest
This patient has osteomyelitis of the humerus with a large subperiosteal abscess. The presence of subperiosteal abscess necessitates surgical intervention for irrigation and debridement (I&D).
The diagnosis of acute osteomyelitis in children is made based upon a constellation of findings including pain, systemic signs of infection, elevated serum inflammatory markers, and imaging studies demonstrative of osseous infection. It is most commonly hematogenously spread to the metaphysis of immature bone, which is highly vascular prior to skeletal maturity. Treatment involves obtaining specimen for culture, empiric antibiotic treatment, and surgical irrigation and debridement of known abscesses. The end-point of treatment is return of pain-free functionality and the resolution of local/systemic signs of infection.
Conrad reviewed the management of acute hematogenous osteomyelitis and emphasized that surgical intervention in the presence of abscess can be both therapeutic and diagnostic: I&D can obtain culture and narrow the antibiotic plan.
Jones et. al. reviewed chronic pediatric osteomyelitis and report that surgery is the mainstay of treatment because removal of dead bone is essential for resolution of infection. This may be performed with sequestrectomy and curettage, with an emphasis on prevention of pathologic fracture, growth disturbances, bone loss, joint involvement, and permanent loss of function.
Figure A is a coronal STIR MRI image of the humerus demonstrating osteomyelitis
with extensive subperiosteal abscess.
Incorrect Answers:
Brodie's abscess is a type of subacute osteomyelitis which remains indolent and creates a focal intra-osseous abscess. This is not demonstrated in the clinical image.
The patient does have osteomyelitis of the humeral metaphysis, but this alone is not the indication for surgery. Uncomplicated osteomyelitis may be treated effectively with antibiotics alone.
Presence of subcutaneous air is suggestive of necrotizing fasciitis, which is a surgical emergency. The MRI however does not demonstrate this finding.
The infection and its surgical management both increase risk of injury to the proximal humeral physis and has the potential for growth arrest or angular deformity.
(SBQ13PE.3) Figure A demonstrates a physical examination maneuver in a 1 month old infant. What is this maneuver?
Review Topic
Ortolani Test
Barlow Test
Galeazzi Sign
Patrick test
Teratologic Sign
Figure A shows a schematic image of the Ortalani test.
The Ortolani test, or Ortolani maneuver, is part of the physical examination for developmental dysplasia of the hip. It is used alongside the Barlow test to detect subluxated hips that are either reducible or irreducible. A positive sign is a distinctive 'clunk' which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Guille et al. showed that the use of Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step before they are able to stand.
Video V is a lecture discussing the hip examination of the infant. Incorrect Answers:
pressure on the knee, directing the force the femoral head posteriorly. A positive Barlow test would result in posterior subluxation/dislocation of the hip. Answer 3: Galeazzi test is performed by flexing an infant's knees in the supine position so that the ankles touch the buttocks. If the knees are not level then the test is positive, which indicates a potential congenital hip issue (e.g. DDH). Answer 4: Patrick or Faber test (flexion, abduction, external rotation) has been described both for stressing the SI joint and for isolating symptoms to the hip Answer 5: Teratologic dislocation of the hip is a term used to imply that the hip joint did not develop normally in utero, thus the hip is in a fixed dislocated position at birth.

Question 97:

Options:

Tibial polyethylene exchange
Revision of the femoral and tibial components and conversion to a posterior stabilized insert
Revision of the femoral and tibial components to a constrained rotating hinge prosthesis
Isolated femoral component revision and upsizing of the femoral implant with a new posterior cruciate ligament (PCL)-retaining polyethylene insert

Correct Answer: Revision of the femoral and tibial components and conversion to a posterior stabilized insert

Explanation:

Question 98:

What is the most common causative bacteria in septic arthritis in children?

Options:

Staphylococcus aureus
Brucella melitensis
Haemophilus influenzae
Kingella kingae
Streptococcus pneumonia

Correct Answer: Staphylococcus aureus

Explanation:

Question 99:

The dorsal (Thompson) approach to the proximal forearm uses which of the following intermuscular intervals?

Options:

Extensor carpi radialis longus and the extensor carpi radialis brevis
Extensor pollicis longus and the extensor pollicis brevis
Extensor digitorum communis and the extensor carpi radialis brevis
Extensor carpi ulnaris and the extensor carpi radialis brevis
Abductor pollicis longus and the extensor carpi radialis brevis

Correct Answer: Extensor digitorum communis and the extensor carpi radialis brevis

Orthopedic Surgery Board Review MCQs: Arthroplasty, Ligament & Spine | Part 149

Orthopedic Board Review MCQs: Hip, Shoulder & Spine Surgery | Part 115

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 115

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index